Impact of free school lunch program on nutritional status and academic outcomes among school children in India: A systematic review

Abstract

Introduction

Mid-day meal programmes (MDM) were introduced in India to improve school attendance, nutritional status and educational outcomes of school children. Numerous primary studies have examined the impact of the MDM programmes on both nutritional and educational outcomes in various settings across the country. However, synthesising the findings from these studies has been challenging. To address this gap, we conducted a systematic review to assess the effects of MDM programmes on the nutritional and academic outcomes of school children in India.

Methods

A comprehensive literature search was conducted, and relevant studies published between 1997 and 2022 were included. Two reviewers independently conducted study selection, data extraction and risk of bias assessment. The results were synthesised descriptively.

Results

The systematic review included 31 studies. Among them, 16 studies focused on academic outcomes, while 18 studies reported children’s nutritional status. Studies on MDM Scheme (MDMS) in children show mixed results on nutritional outcomes. While some studies show marginal improvements in height and weight measurements, others show no significant improvement. Regular MDMS access improves enrollment, attendance and retention rates for children, with lower dropout rates and higher academic achievement. However, its impact on academic performance remains unclear.

Conclusion

The MDM programme in India was effective in improving the academic achievement and a few nutritional outcomes of school children, underscoring the importance of sustaining MDM programmes in India.

Protocol registration number

The review was prospectively registered in PROSPERO (CRD42023391776). Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023391776.

Correspondence to Dr Venkitachalam Ramanarayanan; [email protected]

STRENGTHS AND LIMITATIONS OF THIS STUDY

• A comprehensive search ensured that the review included 31 studies covering a 25-year period (1997–2022).

• Included a number of studies higher than previous similar systematic reviews and exclusively focused on the Mid-Day Meal Scheme in India.

• Both nutritional and academic outcomes were included, offering a holistic perspective on children’s well-being.

• The included studies showed heterogeneity in terms of design, populations and interventions; hence, a meta-analysis was not prudent.

• We excluded studies that used parameters other than numerical data for assessment, such as food quality or stakeholder perspectives.

Introduction

The nutritional status of children is known to significantly impact their cognitive development and academic performance.¹ Implementing health and nutrition interventions within educational systems has shown effectiveness in improving educational outcomes.² Among the various social welfare interventions implemented worldwide, school feeding programmes (SFPs) have positively affected multiple domains, including health, nutrition, education, food security and poverty reduction.^{3 4} According to a report by the World Food Programme in 2022, SFPs are widespread, with nearly every nation implementing them, benefiting approximately 418 million children who receive meals at school daily across 176 developing and developed countries.⁵ These programmes serve diverse objectives, such as providing social safety nets, promoting education, improving nutrition and health and supporting local agriculture.⁶

India’s Mid-Day Meal Scheme (MDMS) is the most extensive school meals programme globally. The implementation of SFPs in India has a long history, dating back to 1925 when the Madras Corporation first introduced meals for school children in Madras city.⁷ In the early 1960s, SFP in Tamil Nadu State expanded significantly. In 1956, the chief minister of Tamil Nadu took the initiative to provide free meals to underprivileged children in all primary schools throughout the state. Building on this foundation, in 1982, the chief minister further extended the scheme to encompass all government primary school children and preschoolers in the state of Tamil Nadu.⁸ Following Tamil Nadu’s initiative, other state governments also adopted the programme, using their resources or with the assistance of international agencies such as UNICEF, WHO and the Food and Agricultural Organization, particularly after India’s independence. Gujarat, Kerala and the Union Territory of Puducherry began offering free lunches to primary school children in the 1980s. By 1990–1991, 12 states were providing free meals to children enrolled in primary schools.⁷

The National Programme of Nutritional Support to Primary Education was initiated on 15 August 1995, as a centrally sponsored programme in 2408 community development blocks. Its objective was to improve school enrolment, retention, attendance and the nutritional status of children. Over the years, the scheme underwent modifications. In 2001, in adherence to a supreme court order, the government initiated the scheme, offering a cooked MDM with a minimum of 300 calories and 8–12 grams of protein to every child in government and government-aided primary schools for at least 200 school days. In 2008–2009, the programme was expanded to encompass upper primary children and in 2009, it was officially renamed as the ‘National Program of Mid-Day Meal’, commonly known as the MDMS.⁹ The National Food Security Act of 2013 mandates the provision of hot cooked meals containing 450 calories and 12 grams of protein for primary class children and 700 calories and 20 grams of protein for upper primary class children. In September 2021, the MDMS was renamed as the Pradhan Mantri Poshan Shakti Nirman Scheme (PM-POSHAN). As a centrally sponsored scheme, PM-POSHAN provides one hot cooked meal per day in government and government-aided schools. In addition to the 118 million students in classes one to eight attending the 1.12 million schools,⁹ the scheme also provides hot cooked meals to children at preschools or Bal Vatika. The programme is available to all children in lower primary and upper primary classes across the country, irrespective of their gender or social background. In the fiscal year 2020–2021, the Indian government invested over ₹244 billion, with food grains alone costing around ₹115 billion.⁹

India, the world’s most populous country,¹⁰ faces significant challenges related to child nutritional indicators.^11–13 While there has been progress in reducing undernourishment,¹⁴ the country continues to grapple with severe hunger, as evident from its 107th rank in the Global Hunger Index-2022.¹⁵ According to the Comprehensive National Nutrition Survey 2019 (CNNS), 21.9% of children aged between 5 and 9 years exhibited stunting, 35.2% were underweight and 31% of children aged 5–19 years displayed compromised nutritional status based on the low mid-upper arm circumference (MUAC). In CNNS-2019, 24% of children aged between 5 and 9 years and 28% of children aged between 10 and 14 years experienced some degree of anaemia as determined by the haemoglobin concentration. The severity of anaemia varied within the different age groups of children; 10% had mild anaemia, 13% had moderate anaemia and 1% had severe anaemia.¹⁶

Academic performance is pivotal in a child’s development, shaping their prospects and well-being. However, numerous factors, including poor nutrition, can negatively affect educational outcomes, impeding cognitive abilities, attention span and learning capacity. In India, ensuring universal access to education has been a priority, resulting in significant progress in primary and secondary school enrolment. According to the World Bank data, the percentage of children not enrolled in schools decreased from 39% in 1971 to 5% in 2020. However, an estimated 3.06 million children are still out of school in 2021.¹⁷

Previous attempts to review this topic have been limited, with some being narrative reviews and some relying on limited survey data. Gousalya et al conducted a systematic review focusing on the MDMS effect on children’s nutritional status in India, although with a limited number of eight studies.¹⁸ The absence of shared terminology and outcome assessments has further hindered the documentation of trends over time and the evaluation of the MDMS’ effectiveness in different settings. Synthesising the findings from these studies has been challenging. To bridge this knowledge gap, we performed a systematic review to analyse the effects of MDMS on the nutritional and academic outcomes of school children in India.

The primary objective of this study was to assess the impact of MDMS on the nutritional and academic outcomes of lower primary (5–9 years) and upper primary (10–14 years) school children in India. Specifically, we aimed to assess the impact of MDMS on nutritional outcomes such as stunting, wasting, underweight and MUAC and academic outcomes such as attendance rates, enrolment, retention, dropout and educational performance. The secondary objective was to compare the impact of MDMS on the above outcomes between government and private schools.

Methodology

Study design and inclusion criteria

This systematic review included studies published between 1997 and 2022 that evaluated the impact of the MDMS in India. The 2-year period since the implementation of the MDMS in 1995 was considered to ensure sufficient time for evaluation. Only studies published in English and employing randomised and non-randomised controlled trial designs, cross-sectional studies, longitudinal studies or before-after studies were included. Review papers, commentaries, methodology papers and studies with inaccessible full texts were excluded. We did not include studies on preschool children since they were included only in the year 2021 at the national level. The protocol was registered with PROSPERO (CRD42023391776).

This systematic review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses¹⁹ and Synthesis without Meta-analysis guidelines to ensure transparency and methodological rigour.²⁰ The Population, Intervention, Comparison and Outcomes framework guided the review process and data synthesis, aligning with the study’s specific objectives.

The target population of this review consisted of Indian, lower primary (5–9 years) and upper primary (10–14 years) children. This encompassed lower primary (grades 1–5) and upper primary (grades 6–8). Studies conducted in school settings, irrespective of gender, socioeconomic status or geographical location, with MDMS intervention were included.

The search strategy for this review considered various terminologies used for the SFP intervention, such as the MDM programme, MDMS, SFP, National Programme of mid-day meal and PM-POSHAN. However, it did not include studies related to SFPs specifically focused on food fortification. The review assessed the impact of MDMS on nutritional outcomes (stunting, underweight, wasting and MUAC) and educational outcomes (enrolment, attendance, retention, dropout and academic performance).

Comparison groups were categorised based on the participants who were beneficiaries of MDMS or not (non-MDMS). The non-MDMS category included other interventions such as home meals or food provided by private schools. Additionally, comparisons were also made between different implementation periods of SFPs, such as before and after the implementation of the MDMS.

Search strategy

To ensure the validity of the research question and avoid duplicating previous studies, a preliminary search was conducted to identify relevant studies. Keywords such as “Mid-day meal,” “school feeding programme,” “school lunch programme,” “PM POSHAN,” “school children,” “attendance,” “enrollment,” “retention,” “dropout,” “academic performance” and “nutritional status” were used. Trial searches and manual searches, including reference and citation searches, were performed to identify any potentially overlooked studies. The search strategy used for the databases was: ((((((((((((mid-day meal) OR (mid-day meal)) OR (“school feeding programme*”)) OR (“school feeding programme*”)) OR (“school lunch programme*”)) OR (“school lunch programme*”)) OR (“school feeding programme*”)) OR (“school feeding programme*”)) OR (PM POSHAN)) OR (PM-POSHAN)) AND (((((((attendance) OR (enrolment)) OR (retention)) OR (drop out)) OR (drop-out)) OR (performance)) OR (nutrition*))) AND ((school*) OR (school children))) AND (India). A systematic search was conducted across several databases including MEDLINE Ovid (from 2000 onwards), Scopus, Cochrane, CINAHL and Google Scholar to identify relevant studies. The search was conducted in March 2023 for all the aforementioned databases (online supplemental file 1).

Search management

The search management and selection process were conducted using Covidence software. Two independent reviewers (LR and VR) conducted the screening process, including title and abstract screening, followed by a full-text assessment for eligibility. Data extraction was performed independently for each selected study, using a customised data extraction template in a Microsoft Excel spreadsheet that was pilot-tested to ensure accuracy and consistency. The extracted information included publication details, study location, study design, study duration, study population, intervention characteristics, outcome data and intervention results. Any disagreements in the screening or data extraction process were resolved through discussion and consensus.

Risk of bias

Joanna Briggs Institute Critical Appraisal checklist tool²¹ was used to assess the risk of bias in individual studies. This tool comprises eight questions aimed at assessing the methodological quality of a study and gauging the extent to which it has accounted for potential bias in its design, execution and analysis. Each included study was judged as Yes, No, Unclear or Not Applicable for eight questions. Studies that received a score of six or above were judged to be at a low risk of bias, a score of four or five indicated a medium risk, while a score of three or less indicated a high risk of bias. Based on the level of risk, the overall quality of each study was then assessed in terms of “Include”, “Exclude” or “Seek further info”.

Qualitative synthesis

The included studies were read in full and relevant data were extracted. Information on different nutritional and academic outcomes was collated and described narratively. The nutritional outcomes included height, weight, stunting, wasting, underweight, body mass index (BMI) and MUAC. Academic outcomes included enrolment, retention, dropout and academic performance.

Quantitative synthesis

Though a meta-analysis was planned in the protocol stage, it could be performed as there was considerable clinical and methodological heterogeneity in the included studies. Study designs used were predominantly cross-sectional in nature due to which causal interpretations cannot be synthesised. Heterogeneity was also noted in the reporting of data (age group, gender, follow-up periods, etc), which deemed it prudent not to undertake a quantitative synthesis.

Patient and public involvement

Patients and the public were not involved in this research study.

Results

Search results

The preliminary search through MEDLINE Ovid, Scopus, Cochrane, CINAHL and Google Scholar databases yielded a total of 180 studies. An additional 28 studies were added from the manual reference searches. Of the total 208 studies, 147 studies remained after excluding duplicates by Covidence software. Out of 147 studies, a preliminary screening of titles and abstracts was conducted. Subsequently, 72 studies were deemed ineligible and were excluded based on the inclusion criteria. The remaining 75 full-text studies were retrieved for full-text analysis. Based on full-text evaluation, 44 studies were excluded and 31 studies were included for qualitative synthesis (figure 1). Brief characteristics of included studies are provided in table 1 and a detailed information is provided in online supplemental file 2, table 1.

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart.

Table 1

Characteristics of included studies

Study ID	Study design	State	Study population (school children)	Type of study	Nutritional outcome	Academic outcome
Jayalakshmi and Jissa, 201722	Cross-sectional study	Kerala	6–10 years	MDMS vs non-MDMS	Yes	No
Thanakachan et al, 202223	Longitudinal study	Karnataka	6–10 years	MDMS vs non-MDMS	Yes	No
Laxmaiah et al, 199924	Cross-sectional study	Karnataka	6–11 years	MDMS vs non-MDMS	Yes	Yes
Sinha et al, 201735	Longitudinal study	Bihar	7–14 years	Before and after comparison	Yes	No
Souza et al, 202136	Cross-sectional study	Not mentioned	6–14 years	Before and after comparison of MDMS vs non-MDMS	Yes	Yes
Bhargava et al, 201425	Cross-sectional study	Uttarakhand	6–17 years	MDMS vs non-MDMS	Yes	No
Minj et al, 201426	Cross-sectional study	Karnataka	6–12 years	MDMS vs non-MDMS	Yes	No
Prakasam et al, 202127	Cross-sectional study	Union Territory Chandigarh	Class 6–8	MDMS vs non-MDMS	Yes	No
Patel et al, 201628	Cross-sectional study	Gujarat	10–14 years	MDMS vs non-MDMS	Yes	No
Nazani et al, 201729	Cross-sectional study	Jammu & Kashmir	Preschool children (<6 years)	MDMS vs non-MDMS	Yes	No
Alim et al, 201230	Cross-sectional study	Uttar Pradesh	10–14 years	MDMS vs non-MDMS	Yes	Yes
Singh et al, 200837	RCT	Andhra Pradesh	6–12 years	Before and after comparison	Yes	Yes
Anima rani et al, 200838	Cross-sectional study	Orissa	Class 1–5	Before and after comparison	No	Yes
Dowarah et al, 202039	Cross-sectional study	Assam	Government school	Before and after comparison	No	Yes
Afridi et al, 202040	Cross-sectional study	Delhi	Primary school	Before and after comparison	No	Yes
Bonds et al, 201231	Cross-sectional study	India	Primary school	MDMS vs non-MDMS	No	Yes
Nath et al, 201541	Cross-sectional study	West Bengal	Class 1–5	Before and after comparison	No	Yes
Mondal et al, 201742	Cross-sectional study	West Bengal	Class 1–4	Before and after comparison	No	Yes
Hamid et al, 201243	Cross-sectional study	Jammu and Kashmir	Children from primary schools	Before and after comparison	No	Yes
Deka et al, 202144	Cross-sectional study	Assam	Class 1–7	Before and after comparison	No	Yes
Singh et al, 202045	Cross-sectional study	Delhi	Class 1–4	Before and after comparison	No	Yes
Avinash et al, 201846	Cross-sectional study	Karnataka	Upper-primary schools	Before and after comparison	No	Yes
Singh et al, 201532	Cross-sectional study	Uttar Pradesh	Government and private schools	MDMS vs non-MDMS	No	Yes
Roy et al, 201833	Cross-sectional study	West Bengal	Government and private schools	MDMS vs non-MDMS	No	Yes
Dey et al, 201834	Cross-sectional study	West Bengal	School children	MDMS vs non-MDMS	No	Yes
Alim et al, 201247	Cross-sectional study	Uttar Pradesh	Government primary schools	Compare the nutritional status of MDMS beneficiaries with ICMR standards	Yes	No
Sachan et al, 201648	Cross-sectional study	Uttar Pradesh	6–12 years		Yes	No
Chethana et al, 201849	Cross-sectional study	Karnataka	6–12 years		Yes	No
Shankar et al, 202250	Cross-sectional study	Uttar Pradesh	6–11 years		Yes	No
Mall et al, 201752	Cross-sectional study	Bihar	6–10 years	Compare the nutritional status of MDMS beneficiaries with WHO standards	Yes	No
Nambiar et al, 201251	Cross-sectional study	Gujarat	School children		Yes	No

MDMS, mid-day meal scheme; RCT, randomised controlled trial.

Risk of bias assessment

All 31 studies (100%) were assessed for bias; clear inclusion criteria for the sample were defined. Among these, 30 studies (96.77%) provided detailed descriptions of both the study subject and setting. Additionally, each of the included studies demonstrated valid and reliable measurements of exposure and outcomes. The standard criteria used for the measurement were outlined in every study (100%). All 31 studies employed suitable statistical analyses. However, only five studies (16.13%) explicitly identified confounding factors and described strategies for addressing them (online supplemental file 2, table 1).

Characteristic of included studies

Characteristics of included studies have been briefed in table 1 and described in online supplemental file 2, tables 1 and 2. This systematic review includes a comprehensive analysis of 31 studies, representing data from 13 states across various geographic regions of the country. The descriptive analysis of the studies revealed that 13 studies^22–34 compared MDMS and non-MDMS interventions, while 12 studies^35–46 assessed the impact before and after MDMS implementation. Moreover, six studies evaluated the nutritional status of MDMS beneficiaries using either the Indian Council of Medical Research (ICMR) or WHO standards. Of these, four studies used ICMR standards^47–50 and two studies^{51 52} used WHO standards.

Among 31 studies, 16 studies focused on academic outcomes, while 18 studies concentrated on children’s nutritional status. For nutritional outcomes, 10 studies compared MDMS beneficiaries to non-MDMS beneficiaries. Within these, seven studies measured height and weight, two studies examined MUAC, three studies assessed stunting and wasting and two studies evaluated underweight. Regarding academic outcomes, six studies compared MDMS beneficiaries to non-MDMS beneficiaries. Attendance was assessed by four studies, enrolment by four studies, retention by three studies, dropout rates by one study and academic performance by two studies.

Studies with comparison of MDMS with non-MDMS

Nutritional outcomes

10 studies were available for comparison of nutritional outcomes between children who regularly consume MDMs and those who did not. Among the seven studies that assessed height and weight, two studies^{24 25} demonstrated marginal improvements in height measurements for MDMS beneficiaries, while five studies^{28–30 35 36} revealed no significant improvement compared with non-MDMS beneficiaries. Similarly, three studies^{24 25 29} indicated marginal improvements in weight measurements in MDMS schools, whereas four studies^{28 30 35 36} found no notable differences between MDMS and non-MDMS groups. MUAC was evaluated in two studies,^{35 36} both of which concluded that MDMS had no positive impact on this measure. Furthermore, two studies^{22 24} highlighted a significant positive impact of consistent MDMS consumption on reducing stunting, underweight and wasting. However, Patel et al ²⁸ reported contrasting findings, indicating that school children receiving MDMS had significantly lower anthropometric measures compared with their non-MDMS counterparts. Overall, the evidence presents a mixed picture of the MDMS’s effectiveness in improving nutritional outcomes.

Four studies^47–50 assessed the height and weight of MDMS beneficiaries and compared them to the standards set by the ICMR. Four studies^47–50 indicated that the height and weight of MDMS school children were lower than the ICMR standards. However, a study by Chethana et al in 2018⁴⁹ revealed that MUAC of MDMS school children was similar to the ICMR standards. Additionally, two other studies^{51 52} compared the nutritional status of MDMS beneficiaries with WHO standards, and their findings indicated that the nutritional status of MDMS school children was lower than that of WHO standards. These comparisons highlight that while some aspects of nutritional status, such as MUAC, may meet national standards, other critical measures like height and weight still fall short of both national and international benchmarks.

Academic outcomes

A study²⁴ indicated that children with regular access to MDMS had better enrolment and attendance rates, lower dropout rates and higher retention rates compared with children without access to MDMS. Supporting these findings, other studies revealed significant improvements in enrolment,^31–33 attendance^32–34 and retention rates³³ among MDMS beneficiaries compared with non-MDMS groups. In contrast, Singh et al ³² did not observe a significant enhancement in retention rates following the implementation of the MDMS. Regarding academic achievement, the study by Laxmaiah et al ²⁴ found that the scholastic performance of children was marginally higher in MDMS schools compared with non-MDM schools. However, another study³⁰ revealed that a lower percentage of MDMS children scored in the highest academic category compared with non-MDMS children, while a higher proportion of MDMS children fell into the middle and lower academic categories. The evidence suggests that the MDMS programme positively impacts enrolment, attendance and retention rates, although its effect on academic performance remains debatable.

Studies with comparison before and after MDMS.

Nutritional outcomes

Based on the comparison of nutritional outcomes before and after the implementation of the MDMS, several studies have been analysed to evaluate its effectiveness. Height and weight assessments across three studies^{26 35 36} revealed significant positive outcomes in two studies,^{26 35} whereas one study³⁶ indicated only marginal improvement post-MDMS implementation. Regarding MUAC measurements, two studies^{35 36} were reviewed: one study³⁶ demonstrated a marginal improvement, while the other study³⁵ reported significant improvement following MDMS implementation. Additionally, underweight and stunting statuses were evaluated in two studies.^{26 35} Minj et al ²⁶ indicated a marked reduction in the proportion of children with underweight and stunting statuses. However, another study³⁷ found no significant reduction in these conditions post-MDMS implementation.

Academic outcomes

A review of 10 studies assessing various academic outcomes before and after the implementation of MDMS, several key findings have been observed. Hamid et al ⁴³ reported substantial improvements in school enrolments, student attendance rates and a considerable reduction in dropout rates following the introduction of the MDMS. Supporting these findings, other studies revealed significant improvements in attendance,^{38 40 44 46} enrolment^{38 39 41 42 46} and dropout reduction^{38 39 41 42 45} compared with the period before MDMS implementation. Additionally, two studies^{37 46} found significant improvements in academic performance following the implementation of the MDMS. Singh⁴⁵ highlighted a notable improvement in school retention rates post-MDM implementation. Consistent with this finding, other two studies^{41 42} also reported significant improvements in school retention compared with the period before the implementation of the MDM programme. Available evidence suggests that the MDMS programme had a positive impact on various academic outcomes, including attendance, enrolment, dropout rates and retention.

Subgroup analysis comparing the effect of MDMS between government and private schools.

A subgroup analysis was conducted to assess the impact of the MDM programme on nutritional outcomes, comparing government schools with MDM implementation to private schools where children consumed home lunch. Six studies^{25 28–30 36 37} were included in this subgroup assessment. The study by Nazni et al in 2017 revealed that the MDM programme did not have a significant positive impact on height, weight and MUAC of children in government schools compared with the nutritional status of children in private schools who consumed home lunch.²⁹ Similarly, studies by Alim et al, Patel et al and Souza et al reported that the MDM programme did not substantially improve height, weight and MUAC in government school children compared with their private school counterparts.^{28 30 36}

BMI was assessed in two studies,^{28 36} both of which revealed that children in government schools receiving MDM had significantly lower BMI measures compared with children in private schools who did not receive MDM. Patel et al also reported that the prevalence of stunting (21.5%) and wasting (17.5%) was significantly higher among government school children receiving MDM compared with non-MDM-receiving private school children.²⁸ Other studies echoed these findings, indicating higher percentages of stunting³⁰ and wasting^{30 37} among MDM recipients in government schools.

Underweight status was assessed in three studies,^{25 28 37} all of which revealed that a significantly higher percentage of children in government schools receiving MDM fell into the underweight category compared with children in private schools who consumed home lunch. Overall, these findings suggest that the MDM programme in government schools may not be as effective in improving nutritional outcomes as the home lunches provided in private schools.

Discussion

Our study found a significant positive effect of MDMS on education outcomes, including school enrolment, attendance, retention and dropout.

Nutritional outcomes

In our systematic review, we found that children who consumed MDMs had significantly lower adverse nutritional outcomes compared with those who did not receive MDMs. However, the analysis did not show a significant positive impact on weight, wasting and MUAC. Studies by Zenebe et al in Southern Ethiopia,⁵³ Wang et al in China⁵⁴ and Gelli et al in Ghana⁵⁵ demonstrated improvements in height-for-age among beneficiaries of SFPs compared with non-beneficiaries. Similarly, studies in Ghana and Kenya reported a lower prevalence of stunting among school children enrolled in feeding programmes compared with those without.^56–58

Furthermore, a meta-analysis by Kristjansson et al ⁵⁹ indicated a small yet significant effect of school feeding on height-for-age. Chakrabarti et al ⁶⁰ investigated the intergenerational nutritional advantages of India’s MDM programme and found that children born to mothers with complete MDM exposure had significantly higher height-for-age compared with those born to mothers without MDM exposure. Notably, it was observed that MDM was linked to a 13%–32% reduction in stunting in India between 2006 and 2016. Moreover, the study emphasised that past investments in MDMs were linked to future improvements in child linear growth. However, a prospective cohort study in Ethiopia,⁶¹ conducted over an academic year, reported no significant improvements in height-for-age among SFP beneficiary children compared with non-beneficiaries.

In terms of weight, a study in Ghana⁵⁶ did not find significant differences in underweight between participating and non-participating schools; studies in China, Bangladesh and Lao People's Democratic Republic observed positive, although not statistically significant, effects on underweight among children attending schools with feeding programmes compared with those attending schools without such programmes.^{54 62 63} Additionally, a meta-analysis in low-income countries revealed a statistically significant effect of school feeding on weight-for-age.⁵⁹ Evidence from few other studies from different parts of the world also suggests that feeding programmes led to positive weight outcomes.^{59 64–66}

There was no significant improvement noted in MUAC before and after the MDM programme. According to CNNS, 32% of children between 5 and 9 years and 31% of children aged 10–19 years in India had low MUAC measurements.¹⁶ Evidence from other global studies suggest that feeding programmes resulted in improvements in MUAC.^{54 65 67 68} Similarly, there was no notable improvement in wasting among children who received MDMs compared with those who did not, although other studies have reported positive effects on wasting.^{58 61 67}

An evaluation of India’s MDM programme highlighted that some children may be hesitant to consume the meals due to perceived issues with quality and limited menu options.⁶⁹ As noted by Galloway et al, children tend to consume less food at home on days when they receive lunch at school, emphasising the supplementary role of school meals alongside home-cooked food.⁷⁰ Another evaluation pointed out that the provision of MDMs often deviates from prescribed norms, with servings frequently falling below the recommended quantity. The quality of these meals, assessed based on sensory attributes and nutrition, varied across schools. Only a minority (29.2%) received a ‘very good’ rating for overall acceptability. However, a significant portion (37.5%) rated ‘poor’ in terms of nutrition and variety.⁷¹

Studies have identified various obstacles in the implementation of MDM programme in India. These encompass financial limitations, delays in supply, concerns about food hygiene and wastage, as well as issues surrounding human resources and corruption. These factors collectively pose significant obstacles to the effective execution of MDMS^{69 71–73} resulting in limited impact on nutritional improvements in children. Funding for MDMS in India is shared between the central government and various states/union territories, with the MDM budget comprising 11% of the Ministry of Education’s total budget in the 2020–2021 fiscal year.⁷⁴ According to the Global Child Nutrition Foundation’s State Survey of School Meal Programmes in India, the MDM scheme reaches approximately 46% of lower primary and upper primary school children (5–14 years old) on average. However, this programme exclusively operates in government/government-aided schools and does not serve the substantial proportion of children attending private schools. The cost of providing MDMs under the scheme averages ₹1121 (approximately US$16) per year for primary school students and ₹1596 (about US$22) for upper primary school students. It is notable that nearly half of the participating states still use charcoal/wood stoves alongside gas or electric stoves in cooking facilities, with some states heavily reliant on charcoal/wood stoves. The monthly honorarium for each cook-cum-helper is ₹1000 (approximately US$14), which may not be considered a living wage.⁷⁴

Academic outcomes

Our systematic review demonstrated a favourable impact of MDM on school attendance. Studies by Kristjansson, Wang and Wall et al’s recent systematic review and Ahmed et al in Bangladesh in African school children, consistently reported increased attendance with SFPs.^{59 64 66 75} Similarly, a study in Southern Ethiopia noted substantial improvements in attendance among children participating in SFPs.⁵³ Collectively, these studies indicate that the impact of free school meals on attendance may be most pronounced in areas experiencing high levels of poverty. Additionally, the prospect of receiving food serves as a significant motivator for school attendance, particularly in lower-income families.⁵³

Our review also revealed an improvement in school retention rates and a notable decrease in dropouts following the implementation of MDM in most studies. Studies from Africa, Kenya and other Low and Middle Income Countries consistently indicated that SFPs contribute to improved retention and reduced dropout rates.^{64 66 75} Providing food incentives to students through school meals serves as a vital measure in offsetting direct educational expenses for parents. This support helps to ensure children’s continued attendance in school, preventing them from being redirected to household chores at home.⁷⁵ Moreover, a Kenyan study emphasises that the provision of food is a primary motivating factor for both attracting and retaining students in school.⁷⁶ It has been observed that continuous SFPs have effectively mitigated the impact of hunger, thereby encouraging sustained attendance. Furthermore, SFPs have demonstrated an additional benefit of enhancing students’ focus and concentration within the classroom, subsequently leading to a decline in dropout rates.^{64 66 75 76}

Regarding academic outcomes, while some studies reported improvements in test scores,^{75 76} Ahmed’s study notably highlighted enhancements in achievement test scores, particularly in mathematics.⁶⁶ A study conducted in Kenya emphasised that well-fed children exhibited prolonged concentration spans, resulting in improved academic performance and, subsequently, better retention rates.⁷⁶ This suggests that addressing short-term hunger, whether in malnourished or well-nourished children, during school hours significantly contributes to active participation in learning activities, ultimately leading to improved academic outcomes.

Despite these positive developments, challenges persist in the Indian education landscape. In 1999, the net primary enrolment rate was a mere 52.5%. Although there was a slight increase in primary school completion rates from 58.7% to 61.4% between 1993 and 2000, high dropout rates remain a concern. According to the Annual Status of Education Report 2022, the proportion of children enrolled in government schools has increased by 7.3% from 2018 to 2022. However, approximately 3.06 million children remained out of school in 2021.¹⁷

A significant factor leading to reduced school participation in India is the financial burden associated with education. Even in cases where schooling is theoretically free, families living below the poverty line often struggle to afford expenses such as books, uniforms, footwear or transportation. These limitations compel children to remain at home, assisting their parents with domestic responsibilities.^{69 73}

MDMS has encountered several well-documented challenges, as highlighted in previous studies. Sinha has pointed out issues like irregular supply, subpar meal quality, instances of corruption and an inconsistent monitoring system.³⁵ Similarly, Prakasam (2021) emphasises the necessity of tailoring the food menu to children’s preferences and nutritional requirements, maintaining hygiene and quality standards, and ensuring timely preparation and service of fresh meals to attract greater participation.²⁷ Furthermore, the programme’s reliance on teachers for monitoring could potentially burden them with administrative tasks, impacting their classroom efficiency. Inadequate kitchen facilities, utensils, water supply and hygienic maintenance are additional reported challenges within the programme’s execution.^{27 35 69 74 77}

Some of these shortcomings can be addressed by the expansion of water and sanitation systems; improvements in the quality and quantity of food, iron and folate supplementation, fortification of food and promotion of consumption of healthy diversified food such as locally available fruits and vegetables. Strengthening community-based interventions, including provision of improved water, sanitation and hygiene, to protect children from infectious diseases is likely to have a positive impact on the programme.

Given India’s diverse sociocultural, regional and economic contexts, it is essential to tailor the MDMS to meet specific community needs keeping in mind the local preferences and cultural milieu. It is noteworthy that the current National Family Health Survey data in India does not encompass the nutritional status of school-aged children. The 2016–2018 CNNS, a nationwide survey, can serve as a valuable reference for understanding the nutritional status of school-aged children. However, for a comprehensive assessment of malnutrition among this age group, it is imperative for the Indian government to conduct a nationwide survey, with a particular focus on district-level estimates, to accurately gauge the extent of the issue.⁷⁸

This study has several key strengths. First, the inclusion of 31 studies covering a 25-year period (1997–2022) demonstrates a comprehensive analysis, providing a robust understanding of the MDM programme’s effectiveness over time. Additionally, we considered both nutritional and academic outcomes, offering a holistic perspective on children’s well-being. Furthermore, our rigorous risk of bias assessment of the included studies ensures that our analysis is based on reliable and robust evidences.

While our study has strengths, there are also certain limitations to consider. The included studies showed heterogeneity in terms of design, populations and interventions, due to which meta-analysis could not be performed. We excluded studies that used parameters other than numerical data for assessment, such as food quality or stakeholder perspectives, as it was beyond the scope of discussion of this paper. These studies could have provided valuable insights into the programme’s overall impact and implementation challenges. By excluding them, we potentially missed insights into the programme’s impact and implementation challenges which in itself requires a comprehensive analysis. Nonetheless, our study contributes valuable evidence to the MDMS and their impact on nutritional status and educational outcomes of school children in India.

Conclusion

Studies included in this systematic review showed that MDMS contributed to improvements in stunting and underweight but did not show much effect on wasting, weight and MUAC. Additionally, the review also noted favourable effects of MDMS on school enrolment, attendance, retention and dropout rates. The study also found that the nutritional outcomes were better in private schools compared with government schools. Addressing shortcomings of MDMS with multi-pronged strategies are likely to have a better impact on nutritional and academic outcomes of school children in India.

The authors wish to thank Shilpa Sara Abraham (MPH student, Amrita School of Medicine) for her support.

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

The review was approved by the Institutional Ethics Committee of Amrita Institute of Medical Sciences (ECASM-AIMS-2023-222 dated 11-04-2023). The authors do not have any financial or other competing interests to declare.

Footnote

Contributors LR: conceptualisation, validation, investigation, formal analysis, writing —original draft, visualisation. VR: conceptualisation, software, validation, investigation, resources, writing—review and editing, supervision, project administration, guarantor. KRT: methodology, formal analysis, resources, data curation, writing — review and editing, project administration, guarantor. During the preparation of this work the author(s) used AI Large Language Models in order to improve the language and constructing of few statements. AI was not used for any new content generation. After using this tool/service, the author(s) reviewed and edited the content as needed.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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