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Beyond school meals

Schoolchildren in green uniforms have talk with PE teacher
Photo credit: LSHTM

School health and nutrition interventions are among the most ubiquitous social programmes worldwide, with one-in-two school children receiving a meal in school each day. However, school health and nutrition services go beyond school meals, with interventions defined as those which are routinely delivered through the school platform to improve the physical health, mental health, diet and nutritional status, and education outcomes of school-age children.

The latest evidence for some of the most common school health and nutrition interventions, summarized by experts from across the Research Consortium’s global network of academic and implementing partners, can be found below.

Discover the latest evidence on school health interventions

Disability

Summary

At least one in ten children of school-going age (5 to 17 years) have a disability.1 Children with disabilities are 49% more likely never to have attended school relative to children without disabilities,1 and so will miss out on school-based health interventions as well as educational opportunities.

Overview of global burden

Approximately 13% of all children aged 5 to 17 have a disability.1 Children with disabilities face barriers in their educational lives globally, including non-enrolment to school, early dropout and poorer educational attainment.1, 2, 3

Children with disabilities are consequently less likely to receive school-based health interventions, including school-based nutrition programmes. This is an important problem, as children with disabilities are significantly more likely to experience malnutrition4, including a three-fold higher prevalence of being underweight, and two-fold higher prevalence of stunting or wasting.5 Moreover, they may have increased healthcare needs compared to other children, which could be met in part with well-designed school health programmes. For instance, they may require assistive devices 6or other forms of school-based specialised support delivered by health professionals (e.g., mental health support, physiotherapy),7 and are more likely to be victims of violence and bullying at school,8 due to widespread stigma and discrimination.9,10

The solution

Global education systems must become inclusive for children with disabilities, including increasing their enrolment and attendance. 11,12 For instance, providing information on the income-relevant benefits of education to parents is an established, low-cost intervention for increasing children’s school attendance and learning outcomes.12

  • Within school-based health programmes, nutrition interventions are considered an effective approach to improve nutritional status.13 Making mainstream school-based nutrition programmes disability-inclusive and providing additional special services for children with disabilities is therefore a key recommendation.4,14

Furthermore, school-based programmes should be broadened to provide necessary health interventions for children with disabilities, including eye and hearing screening and other associated interventions (e.g. speech and language support). School health programmes must ensure that they are also available in both mainstream and special education schools.

Addressing the attendance disparities among children with disabilities also requires additional, tailored intervention strategies beyond that provided to children as a whole.11

Cost

There is presently a lack of robust cost data to inform disability-responsive budgeting in school systems and among school-based interventions.15 However, there is evidence that the returns on such investment would be significant (e.g., provision of AT to children with disabilities who need it to attend and learn in school is estimated to yield USD 100,000 in lifetime earnings per child).16 However, all children have the right to a quality education, including children with disabilities meaning adequate investment is crucial no matter the returns.

Latest guidance

Associated active organisations

Inclusive education:

Nutrition:

Corresponding author

Professor Hannah Kuper ([email protected]), Dr Mark Carew ([email protected]); International Centre for Evidence in Disability

References

View the full list of references

Indigenous Peoples

Summary

School meals that use locally-sourced Indigenous foods help children eat better, celebrate their cultures, strengthen their knowledge and connection to their surrounding environments, and support Indigenous farmers, Indigenous fishers, hunters, gatherers and foragers. In fragile and conflict-affected and displacement-affected settings (i.e., refugees), such programmes could also function as social protection measures, reducing children’s vulnerability to exploitation and insecurity.

Overview of global burden

Indigenous children face disproportionately high levels of malnutrition, poverty and food insecurity compared to non-Indigenous peers. Geographic isolation and limited access to services exacerbate inequalities, contributing to lower school attendance, poor dietary diversity, anaemia and micronutrient deficiencies. In conflict-affected and displacement settings, including refugee and internally displaced communities, food insecurity further reduces attendance as families prioritise immediate survival needs. Prolonged instability and poverty increase children’s vulnerability to child labour, early marriage, exploitation, and recruitment by armed or criminal groups when they are out of school. Schools serve as critical protective environments, yet hunger remains a major barrier to learning and retention. Addressing malnutrition among Indigenous children is therefore not only a health and education priority, but also a social protection and violence-prevention imperative in fragile contexts where insecurity and economic instability threaten long-term community resilience.

Solution

By linking school meals to Indigenous farmers, fishers, hunters, gatherers, foragers and culturally significant local foods, Home-Grown School Feeding (HGSF) strengthens Indigenous determinants of health while addressing structural barriers such as geographic isolation and economic marginalisation. In protracted refugee settings, where restricted movement and uncertainty undermine mental well-being, participation in local food production restores agency and reinforces community cohesion. Reliable school meals incentivise attendance, reduce household food burdens, and stabilise schools as safe and protective spaces. Increased retention lowers children’s vulnerability to exploitation, recruitment by armed groups, and involvement in criminal networks in high-risk contexts. At the same time, local procurement improves affordability and sustainability by reducing transport costs and generating income for Indigenous producers. Through capacity building and Indigenous-led governance, HGSF operates as a cost-effective strategy that simultaneously advances nutrition, livelihoods, food sovereignty, and long-term community resilience.

Cost

Cost of implementation per year will likely vary depending on procurement models and local production capacities, as well as student age. In countries in Latin America and the Caribbean that are implementing HGSF, for example, the typical cost of school meals ranges between US$ 40–100 per child per year, depending on menu composition, logistics, and decentralization.

Evidence from Kenya (Proietti et al., 2025) demonstrates that integrating locally available and Indigenous foods can significantly reduce the cost of delivering a nutritionally adequate school meal while improving dietary diversity. A 2024 linear-programming analysis found that a fully nutritious school meal can cost as little as US$ 0.13 per child per day when menus incorporate Indigenous and underutilized species such as African nightshade, spider plant, Bambara groundnut and local pulses. These foods not only lower costs compared to conventional menus but also improve micronutrient density and reduce meal monotony. This supports HGSF models in Indigenous Peoples’ communities, where traditional crops are already well adapted to local conditions and culturally preferred.

Local sourcing from Indigenous farmers, fishers, hunters, gatherers, foragers combined with use of traditional crops can further reduce transport costs, and strengthen local economies.

Latest guidance

Associated active organisations

Youth ambassador

Diallo Aminata ([email protected]), Indigenous to the Kel Tamasheq and Fullani Community, from Timbuktu, Mali.

Diallo is a Master’s student in Justice and Transformation at the University of Cape Town and a member of the Arramat Project, focused on Indigenous Peoples' participation in transitional justice, child protection, health/biodiversity and overall wellbeing.

Corresponding author

Indigenous Peoples’ Food Systems Coalition

Chair: Aluki Kotierk, [email protected]; and Head of Secretariat: Alejandra Pero, [email protected]

Malaria prevention and treatment

Summary

Malaria undermines the health and education of school children. Education around malaria and bed net use are important components of health education and participatory methods can enhance update. Recent evidence shows malaria infection, related disease, and anaemia can be substantially reduced by the intermittent administration of a curative dose of antimalarial drugs (chemoprevention) in schools translating into improved education and decreased transmission.

Overview of global burden

School-age children suffer an underappreciated burden of malaria with 500 million school-age children at risk of disease.1 Malaria in school children manifests as both acute clinical illness and chronic infections leading to school absences, decreased cognitive function, and lower educational achievement2–4. Because infection is also associated with lower socio-economic status and lower caregiver education levels, malaria widens the education gap both within malaria-endemic areas and between malaria-endemic and non-endemic areas. Furthermore, school-age children are an important reservoir of human-to-mosquito infection perpetuating malaria transmission and challenging malaria elimination efforts.5,6 Universal malaria interventions, such as bed nets and access to prompt diagnosis and treatment, are assumed to cover this age group. However, school-age children are the group least likely to benefit from these interventions.4,5 Thus, interventions specifically targeting this age group are needed.

Decreasing the burden of malaria in school children offers the opportunity improve student health and education as well decrease parasite transmission to younger children who are at higher risk of severe disease and malaria-related mortality. Ultimately, improved learning and decreased malaria transmission both lead to increases in human capital and economic gains.

The solution

In all malaria endemic areas, the foundation of malaria control in school children is built upon effective malaria education as a component of health curricula and improving school children’s access and utilization of universal malaria control interventions (bed nets and prompt, effective diagnosis and treatment). Health clubs, drama groups and other peer-to-peer participatory methods have been utilized to increase malaria related knowledge attitudes and practices.7

In areas with moderate to high malaria transmission, intermittent preventive treatment of malaria in school children (IPTsc) is recommended to further decrease the burden of disease.8 IPTsc, which is the administration of a full treatment course of an antimalarial medicine at regular intervals to treat and prevent malaria infections in children who are old enough to attend school, has demonstrated efficacy to decrease clinical malaria, infection and anemia.9 More limited but increasing evidence suggests IPTsc also improves cognition10,11 and decreases transmission11–13.

Latest guidance

Associated active organisations

Corresponding author

Lauren Cohee, Reader in Paediatrics and Child Health, Liverpool School of Tropical Medicine

Email: [email protected]

References

View the full list of references

Menstrual health

Summary

Menstrual health is an increasingly recognised public health issue1,2. There is growing consensus that multi-component interventions addressing physical and emotional aspects of menstrual health are needed to improve menstrual management3, and potentially also educational attainment, mental health problems, and quality of life among girls in school.

Overview of global burden

Menstrual health is defined as complete physical, mental, and social wellbeing in relation to the menstrual cycle4. Improving menstrual health is essential to meeting the Sustainable Development Goals for gender equality, good health, quality education, sustainable water and sanitation and related human rights5. Challenges to achieving good menstrual health among girls include inadequate puberty education and knowledge, lack of social support from teachers and peers, and insufficient access to appropriate products and water, sanitation and hygiene (WASH) infrastructure3. These psychosocial and physical challenges to menstrual health impact on girls’ ability to succeed and thrive mentally and physically within the school environment and beyond6,7. Menstrual health may also impact on educational outcomes but few intervention studies have evaluated this8.

The solution

Studies are evaluating sustainable, low-cost menstrual health interventions for secondary schools in Uganda, The Gambia and Tanzania respectively. These are multicomponent interventions which include some or all of the following components: puberty education, drama skit, provision of a menstrual kits/training, pain management, WASH improvements, creation of Menstrual Health Action Groups, Mother’s clubs and community meetings. We have completed the evaluation of MEGAMBO which showed no changes in school attendance whilst menstruation but positive changes on menstrual stress, social support, and menstrual KAP among Gambian schoolgirls. Following formative research9 and piloting10-13,we are currently evaluating MENISCUS intervention through a cluster-randomised trial in 60 secondary schools in Uganda (primary outcomes are educational performance and mental health symptoms). Similarly, the PASS-MHW project is evaluating the TWAWEZA intervention as a scalable comprehensive menstrual health intervention to be integrated into the government school system to improve menstrual health and psychosocial wellbeing for optimal school participation and performance of secondary school girls.14

Latest guidance

Associated active organisations

Youth ambassadors

Mandi Tembo ([email protected]) About | The Bleed Read

Mandi Tembo is a young Zimbabwean researcher with over 10 years working experience in sexual health research and advocacy. Currently, she is a Fogarty Fellow and PhD candidate at the London School for Hygiene and Tropical Medicine. Her work looks at the integration of menstrual health in SRH provision and investigates menstrual product choice and MH knowledge, practices, and perceptions among young women in Zimbabwe. She has published in the areas of HIV, adolescent health, gender transformation, and MHH. Mandi is also the founder of The Bleed Read – a virtual platform that comprehensively addresses and highlights all things menstrual health related.

Vishna Shah ([email protected])

Jennifer Rubli ([email protected])

Corresponding author

Helen Weiss, Professor of Epidemiology, London School of Hygiene & Tropical Medicine

Email: [email protected]

References

View the full list of references

Physical activity

Summary

Comprehensive approaches that combine built environment, education, and policy change. Two examples are School Wellness Integration Targeting Child Health (SWITCH®) and the Physical Activity 4 Everyone (PA4E1) Programs.

Overview of global burden

Physical inactivity is a global public health concern;1,2 lack of activity is associated with risk for chronic disease such as overweight/obesity, diabetes, and cancer.3 Many studies have been conducted to examine prevalence in youth; researchers agree that children do not meet the recommended 60 minutes of moderate-to-vigorous physical activity per day, girls/females are less active than male counterparts, and physical activity behaviour declines with age.1 Unfortunately, children and youth in low-income situations are most at risk for physical inactivity due to issues of safety, cost, and issues with the built environment.4-6 Accordingly, schools provide an unmatched setting to reach children and provide safe opportunities for physical activity among other health behaviours. Building capacity in these systems is a worthwhile investment for facilitating behaviour change; these interventions are arguably more sustainable because of systemic change within school culture.

The solution

Both the SWITCH and PA4E1 interventions have been scaled up from prior successful efficacy trials,7-11 which were more costly, to implementation interventions whereby facilitation and training are provided to school professionals to implement a comprehensive program on their own.12-15 Both rely on a continuous cycle of training, implementation, and evaluation to facilitate continuous improvement over time. Both interventions comprise several key elements that make them successful: 1) education materials (e.g., curriculum); 2) teacher training through in-person/online professional development; 3) enacting school-level policies for activity promotion; 4) parent outreach; and 5) community engagement. As these interventions moved from efficacy to implementation and sustainability, the focus is predominantly on building and sustaining systems that promote physical activity.

Latest guidance

Associated active organisations

Corresponding author

Gabriella M. McLoughlin, Assistant Professor, College of Public Health, Temple University, Philadelphia

Email: [email protected]

References

View the full list of references

Surgery

Summary

While the development from child to adult spans the first 8,000 days (or 21 years) of life, much of the focus in global child health has been on the first 1,000 days of life (between conception and the 2nd birthday) with a neglect of surgical conditions within this age group and the next 7,000 days. To achieve universal health coverage for children in lower- and middle-income countries (LMICs), there is an urgent need to invest in surgical care within the first 8,000 days of life.

Overview of global burden

It is estimated that surgical conditions account for up to 30% of the global burden of disease, and this is more than the burden of malaria, tuberculosis and human immunodeficiency virus (HIV) combined. In low- and middle-income countries where children and adolescents make up about 50% of the population, there is a disproportionately higher burden of children’s surgical disease. In children and adolescents, surgery is vital in the management of surgically correctable congenital anomalies, life threatening injuries and burns, infections, cancers and a host of other conditions.

Congenital anomalies are responsible for 25.3-38.8 million disability adjusted life years (DALYs) worldwide and in 2019, ranked as the fifth leading cause of mortality in children under 5 years of age. In the same year, in children under 5 years of age, unintentional injuries accounted for 21.56 deaths per 100,000 and transport injuries 6.16 deaths per 100,000 while among children aged 5-14 years, unintentional injuries were responsible for 7.09 deaths per 100,000 and transport injuries 4.54 deaths per 100,000, ranking as the second and fourth leading cause of death within U5 and 5–14-year age groups respectively

In the management of cancers in children and adolescents, surgery plays key roles in diagnosis and definitive treatment. There are regional disparities in cancer incidence and survival with low development index countries having a 5-year survival as low as 20%. Children surgical infections and child and adolescent reproductive health problems requiring surgical intervention also contribute significantly to the burden of surgical diseases within the age group.

The increasing knowledge and awareness of the huge burden of surgical diseases in children and the role of surgery in improving the survival and quality of life in children have however not translated into inclusion of children’s surgery in public child health agenda, population-based strategies and interventions.

The solution

Incorporating education of teachers and students on common surgical conditions in school health programmes and immediate steps taken on early detection of such conditions will improve awareness of the conditions and availability of care, and ultimately significantly reduce delayed presentation with improved outcomes. Focused training on preventive measures against intentional and unintentional injuries is a strategy that can reduce the burden of injuries. Additionally, a checklist to screen for potential neglected congenital anomalies has also been shown to be effective. An important surgical infection in LMICs is typhoid ileitis leading to perforation. Education on hygienic practices and improving sanitary conditions with focus on waste disposal and handling and processing of food and drinks will help reduce the prevalence of this condition. These solutions need to be contextualized to the school environment ensuring that the children are active participants in the educational activities and not passive recipients.

Latest guidance

Associated active organisations

Corresponding author

Justina Seyi-Olajide, Consultant Paediatric Surgeon, Lagos University Teaching Hospital, Lagos, Nigeria

Email: [email protected]

Doruk Ozgediz. Professor of Surgery, Director, Center for Health Equity in Surgery and Anesthesia, University of California, San Francisco; Chair, Global Initiative for Children’s Surgery

Email: [email protected]

References

View the full list of references

Vision and eye health

Summary

Poor vision in children has been associated with lower levels of educational attainment across a range of settings.1-6 Many conditions can cause poor vision in children, and most are preventable or treatable: up to 95% of children with poor vision need little more than a pair of glasses to improve their sight.7-13

Overview of global burden

Over 450 million children have poor vision globally5,14-16, with the highest prevalence in South Asia, Southeast Asia and Western Sub-Saharan Africa. Children with vision loss in low- and middle-income countries (LMICs) are up to five times less likely to be in formal education,6 and poor vision has been shown to severely impact educational outcomes,1,2,17,18 contribute to low self-esteem3 and future socio-economic potential.4 While there are many conditions can cause poor vision in school-aged children, most are preventable or treatable. Without vision screening children will not be able to gain access to the treatment or rehabilitation they need. This will have a lasting impact on educational attainment and learning, affecting their life chances and quality of life.  School-based vision screenings provide a unique opportunity to provide comprehensive eye health services to more than 700 million children throughout the world,19 but eye health is typically omitted from school health interventions, particularly in LMICs.20

The solution

School eye health programmes are cost effective,21 and their benefits can be large. Simply screening children for poor vision and providing eyeglasses to those who need them can make a major difference. The Lancet Commission5 reported spectacles to be one of the most effective health interventions for children. Not only have they been found to reduce the chance of failing a class by 44% (p<0·01),18 they improving educational performance, with effect sizes at least as large as other health interventions.1,2,17,18,22 School-based vision screening will also allow the detection of other eye conditions requiring attention, and ensure that the children affected are referred promptly for treatment. Comprehensive school eye health programmes also include health education and promotion that can lead to positive social behaviour change. These programmes also support inclusive education for children with irreversible vision impairment, ensuring that the potential of every child is unlocked, leaving no one behind. School-based vision screening will amplify sector-wide investments to support quality education (SDG4), efforts to reduce poverty and hunger, and enabling work (SDGs 1, 2, and 8).23

Latest guidance

Associated active organisations

Further reading

Corresponding author

Graeme MacKenzie, Director, Riemann Ltd

Email: [email protected]

References

View the full list of references