Impact of adding milk to a micronutrient fortified school feeding program: An effectiveness trial in Yemen Lily Bliznashka | IFPRI On behalf of Aulo Gelli, Monica George Michail, Dalia El Sabbagh, and the School Milk Initiative Trial Group Washington, DC | January 28, 2025 Background  In 2023, 76% of children (1.9 billion) under 18 years of age lived in conflict-affected zones (Østby & Rustad 2024)  Conflict impacts mortality, morbidity, and malnutrition in the short- and long-term in addition to weakening food and health systems, markets, and institutions (Altare et al., 2013; Justino, 2012)  School feeding can improve children’s nutrition, health, and education, and improve child safety, protect against risks and disruptions, provide a sense of normalcy, and improve household food security and resilience  However, there is limited rigorous data on the costs and effectiveness of school feeding in humanitarian crises 2 Background  50% of the population in Yemen is food insecure, due to ongoing conflict, associated long-lasting economic decline, and high food and fuel prices  Malnutrition is also prevalent in school-aged children, with 16% of boys and 11% of girls underweight, and 22% of boys and 23% of girls overweight.  In 2022, 17% of school children received school meals oWFP provided imported fortified snacks (date bars or high-energy biscuits) to 1.55 million school children 3 Background  Extensive formative research on how to improve school feeding showed that (Bliznashka et al. 2024) oDate bars and high-energy biscuits (HEBs) are highly cost-efficient in terms of nutrient delivery oThere are issues around palatability. Biscuits are hard and difficult to swallow oCaregiver and children want a beverage (juice, milk, water) oLong-term desire for hot meals, prepared at school using locally sourced ingredients oHybrid scenarios like HEB+milk provide a “middle-option” that improves quality of the meal as program transitions towards healthy meals 4 Impact evaluation of the School Milk Initiative  Cluster randomized controlled trial aimed at evaluating cost, cost-efficiency and impact of adding a daily drink of milk to ongoing fortified biscuit school feeding program  42 schools in Al Mukha district were randomized to either control or milk group oControl: 100 grams (2 packets) of HEB per day oMilk: 100 grams of HEB + 120 ml of UHT milk 5 Control Milk Pathways of impact: biological 6 HEB only HEB+Milk Optimal HEB consumption -some evidence this is not the case in practice… HEB only HEB+Milk Without milk, HEB consumption is sub-optimal in HEB only group N ut rie nt in ta ke N ut rie nt in ta ke 25. Improved physical and mental health Processes 24. Improved nutrition 16. Increased access to nutritious food 13. Increased income 15. Improved knowledge of nutrition, health, hygiene, WASH, and food safety 14. Improved empowerment/ gender equity 9. SF program delivered on- time, uninterrupted, and as planned - healthy meal - THR - cash 2. Selection and refinement of SF program and complementary programming 23. Improved diet quality (usual intake & habits) OutcomesOutputs Impacts 1. Situation analysis conducted Inputs 19. Improved health, hygiene, WASH, and caregiver practices 5. Quality implementation of SF program 17. Improved dietary practices (daily intake & habits) - school meal - food at home - food environment 7. Complementary program components delivered 8. Families/ parents provide food at home 11. Complementary program components received 27. Improved learning 26. Improved attention & cognition 22. Improved school participation 3. On-going engagement with SF stakeholders 4. Provision of technical assistance on all SF aspects 12. Children receive food at home 10. Relevant value chain actors trained 6. Training for relevant value chain actors delivered 18. Improved food environment 2a. Development of meal and supply chain standards 2b. Development of procurement strategy to deliver standards Pathways of impact: behavioural Program impact pathways Child diet Household income School attendance 9. SF program delivered on- time, uninterrupted, and as planned - HEB - Milk Child health -physical (height, weight) -psychosocial (behaviour, stress cognition) Household food security Child learning Caregiver mental health 7 Study design  Primary school aged children enrolled in schools supported by the school feeding program and their caregivers  Baseline conducted in Dec 2023 – Jan 2024 and endline in Apr-May 2024  Intention-to-treat analysis using linear mixed effects models accounting for the cluster design 8 Results 9 Study participants  1,285 children  9 years of age at baseline  ~50% boys and ~50% girls 10 Results Level Dimension Indicator Milk vs Control Household Food security Severe or moderate food insecurity ↓ 14% Caregiver Health Severe anxiety disorder ↓ 1% Child Diet Milk consumption ↑ 58% Dietary diversity Health Had cough ↓ 20% Nutrition Weight, height, body mass index School participation Attendance Attention & cognition Conduct problems ↓ 32% Cognition score ↑ 17% Learning Literacy score ↑ 24% Numeracy score ↑ 47% Note: Greyed boxes indicate no significant differences between the treatment groups 25. Improved physical and mental health Processes 24. Improved nutrition 16. Increased access to nutritious food 13. Increased income 15. Improved knowledge of nutrition, health, hygiene, WASH, and food safety 14. Improved empowerment/ gender equity 9. SF program delivered on- time, uninterrupted, and as planned - healthy meal - THR - cash 2. Selection and refinement of SF program and complementary programming 23. Improved diet quality (usual intake & habits) OutcomesOutputs Impacts 1. Situation analysis conducted Inputs 19. Improved health, hygiene, WASH, and caregiver practices 5. Quality implementation of SF program 17. Improved dietary practices (daily intake & habits) - school meal - food at home - food environment 7. Complementary program components delivered 8. Families/ parents provide food at home 11. Complementary program components received 27. Improved learning 26. Improved attention & cognition 22. Improved school participation 3. On-going engagement with SF stakeholders 4. Provision of technical assistance on all SF aspects 12. Children receive food at home 10. Relevant value chain actors trained 6. Training for relevant value chain actors delivered 18. Improved food environment 2a. Development of meal and supply chain standards 2b. Development of procurement strategy to deliver standards Program impact pathways Child diet Household income School attendance 9. SF program delivered on- time, uninterrupted, and as planned - HEB - Milk Child health -physical (height, weight, morbidity) -psychosocial (behaviour, stress cognition) Household food security Child learning Caregiver mental health Pathways of impact: behavioural 12 Consistently larger effects among girls Discussion 13 Discussion  Rigorous evidence presented in this study suggests that short-term (~5 mo) school milk provision alongside fortified HEB had important benefits for children and their families in Yemen oResults largely consistent with evidence on benefits of school feeding in the literature… plus new results on mental health during conflict oRemarkable result, considering short-time frame of the study and context in which intervention was implemented oHighlights key role of school feeding during humanitarian crises 14 Discussion  Strengths of study include cRCT design and use of combination of subjective and assessment-based indicators  Limitations include small scale pilot concentrated in Al Mukha district, findings may not generalize  In conclusion, hybrid models are acceptable, feasible, and lead to meaningful benefits for vulnerable populations (children and their caregivers) oOpportunities for scale up?  Important gaps remain on costs, on medium- and long-term benefits of intervention and on localizing supply chain 15 Acknowledgements  Trial leads: Aulo Gelli, Lily Bliznashka  IFPRI consultants: Monica George Michail, Dalia Elsabbagh, and in- country colleagues  Implementation team: WFP, HSA, HDB, Tetrapak  Data collection team  Funding: oThe study is funded by the CGIAR and HSA oThe funders had no role in the study design 16 Thank you! 17 Slide Number 1 Background Background Background Impact evaluation of the School Milk Initiative Pathways of impact: biological Slide Number 7 Study design Results Study participants Results Slide Number 12 Discussion Discussion Discussion Acknowledgements Thank you!