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Additional file 1: Figure S1. Flow diagram of the survey organogram. Survey management and supervision was cascaded in such a way that the Ethiopian Public Health Institute team led and oversaw the whole survey. Regional States supervisors supported their respective teams. The overall mapping implementation was checked by external supervisors.

The education sector is crucial to any national response to the world epidemic of HIV and AIDS. The school age years, about 5 to 15 years, make up the cross section of any population with the lowest prevalence of HIV infection. This is the “Window of Hope", and education is the social vaccine against HIV infection. Now, with effective anti-viral treatment increasingly available, the number of infected children of school age is rising through increased survival. Schools must adapt to having more such children in class. Furthermore, there will be many infected and affected children, orphans and vulnerable children, who will not access formal education, or not fully, and the path to education must be made easier for them. We are able to predict a rise and then a fall of the school age numbers, but new preparations must be made for these young people to adapt to their adult lives, living with HIV. All such school and educational responses must take the developmental stages of children and their emotional needs into account.

This review highlights three main findings. First, school feeding programs in low-income countries exhibit large variation in cost, with concomitant opportunities for cost containment. Second, as countries get richer, school feeding costs become a much smaller proportion of the investment in education. For example, in Zambia the cost of school feeding is about 50 percent of annual per capita costs for primary education; in Ireland it is only 10 percent. Further analysis is required to define these relationships, but supporting countries to maintain an investment in school feeding through this transition may emerge as a key role for development partners. Third, the main preconditions for the transition to sustainable national programs are mainstreaming school feeding in national policies and plans, especially education sector plans; identifying national sources of financing; and expanding national implementation capacity. Mainstreaming a development policy for school feeding into national education sector plans offers the added advantage of aligning support for school feeding with the processes already established to harmonize development partner support for the education for all-fast track initiative.

Providing nutritionally balanced diets through ecologically sustainable and equitable food systems is the most profound challenge facing us today. The current state of food and nutrition security is in many ways is a legacy of the green revolution and neoliberal market based political economy. Technocratic and market- based approaches have contributed to creating a highly homogenised food system at the expense of diversity, ecological sustainability and nutrition quality. The origin of agriculture around 10000 years ago and the processes of domestication provide useful insights on the key drivers of food production that influence policy and programmes even today. More importantly there is compelling evidence which shows how the transition to agriculture adversely impacted human health in a wide range of contexts. The study is an action research project primarily based on design, implementation and evaluation of ‘Home Grown School Feeding’ in eight districts across the three main agroecological zones of Nepal. It provides important policy and programmatic evidence on enabling decentralized food systems which are nutritionally and ecologically sensitive, as part of a government led universal food-based safety net project. Based on action research inquiry process, the thesis develops concepts and theories through the different chapters to contribute to our understanding of food systems and programme design. The intervention creates an effective platform for food system mediation through different pathways. Evidence on intervention governance through ‘food sovereignty’ lens demonstrates how HSGF interventions can also promote equity in food systems in terms of policies, funding and knowledge. COVID-19 pandemic control measures have contributed to undermining food and nutrition security, with the poorest being hit the hardest and young children potentially facing life-long consequences. Overall evidence from the thesis including the recent Covid crisis highlights the importance of resilient and context sensitive food production and it is an emphatic reminder of the need to have integrated public health-nutrition-ecology approach to food systems. Open Access

School feeding programs are gaining increasing recognition for their twin roles as a long-term social protection investment as well as acting as a productive safety net for children and their families in the short-term. This was the conclusion of an analysis undertaken by the World Bank and the United Nations World Food Program (WFP), in collaboration with the Partnership for Child Development (PCD), with the aim of understanding why so many poor countries were using school feeding programs as a key part of their response to the emerging food, fuel, and financial crises of 2008. The analysis, published as Rethinking School Feeding (Bundy et al., 2009), showed that governments viewed school feeding programs as providing multiple benefits to education, to health, and to local agriculture, and as being important and readily expandable mechanisms to reach the most vulnerable. Whether called ‘school food’, ‘school meals’ or ‘school feeding’, these programs met most of the important criteria for a productive safety net. This Sourcebook is the third analysis of school feeding by the same three partners, and was produced in response to demand from governments and development agencies for operational guidance on the operational experiences of national programs. This analysis uses a standardized approach to provide a more in-depth understanding of individual programs from 14 different countries, and then to compare their case studies to see what lessons can be learned. The following 14 countries were selected to provide diversity in geography, approach, and development: Botswana, Brazil, Cape Verde, Chile, Cote d’Ivoire, Ecuador, Ghana, India, Kenya, Mali, Mexico, Namibia, Nigeria, and South Africa.

The target groups for many nutrition interventions are mothers and children under the age of two, as evidence has shown significant and substantial benefit for these age groups. Less is known about the potential for school-age children to benefit nutritionally from interventions through a complementary, life-cycle approach. The central hypothesis tested here is that nutrition-sensitive interventions can improve growth at school-age and that schools are an effective platform for children to be able to access these interventions. I address this hypothesis by examining three key research questions: 1) whether and to what extent catch-up growth can occur at school age; 2) how household characteristics (agriculture and dietary quantity and quality in particular) are related to nutrition at school age and what entry points may exist for holistic intervention; and 3) how school feeding programs are related to education participation (and thus access to nutritional inputs through programming) and how programs may be strengthened to improve links with local agriculture. Examining the first question, in a review of the potential for catch-up growth at school age, a range of intervention studies counter claims of the irreversibility of pre-school growth faltering with evidence that early deficits can, at least to some extent, be made up in childhood and adolescence. For the second question, in analysis of relationships between school-age nutritional status and household agriculture in Mali, associations were observed between household agricultural production variety and measures of dietary diversity and food variety, but no associations between these measures and school-age child nutrition outcomes were found. In making the link to programming through the third question, no significant associations were found between school feeding and the education participation outcomes measured at the school level in Kenya. I conclude that opportunities for improving the nutrition of school-age children do exist and that understanding the potential for agriculture-nutrition disconnects and the dynamic nature of school feeding programs could help improve the design of multi-sectoral, nutrition-sensitive interventions at school age, including Home Grown School Feeding (HGSF). Open Access

Globally, over the last decade primary school access has improved significantly. Yet challenges remain: 67 million primary school-aged children are not in school. Poor nutrition and health among schoolchildren are important barriers in achieving education-for-all goals. School feeding is a popular intervention supporting the education, health and nutrition of children in food-insecure settings. However, school feeding programmes are complex, involving a broad range of stakeholders across different sectors and implementation levels. This thesis is aimed at providing evidence to support policy-makers in managing trade-offs among alternative targeting approaches, feeding modalities, and costs. This work is also aimed at building an evidence-based framework to guide Governments in managing the inherent complexity of school feeding interventions. The thesis includes an analysis of a natural experiment involving survey data from 32 countries across sub-Saharan Africa that suggested that school feeding increased enrolment by 10 percent. Enrolment changes varied by modality and gender, with onsite meals having stronger effects in the first year of treatment in lower grades, and onsite combined with take-home rations being effective post-year 1, particularly for girls. Expenditures across 62 countries indicated considerable differences in costs across modalities, ranging from $23 USD for fortified biscuits to $75 USD for take-home rations. This raises important questions of cost-effectiveness and sustainability, also in terms of school-level costs not normally captured in programme expenditures. Findings also suggest that school level costs are substantive, and are a considerable overhead, considering that these costs are generally borne by food-insecure communities. The thesis also highlights that scaling-up school feeding requires significant financing, on average equal to 40 percent of primary education costs. Despite these opportunity costs there is strong buy-in on school feeding from governments in sub-Saharan Africa. The implications of this thesis also suggest that the complexity of school feeding as an intervention has perhaps been underestimated by policymakers. Strengthening the evidence linking outcomes to the design of school feeding and to the quality of the service delivery, including the trade-offs between implementation modalities, remains a critical area of future research. This thesis provides both a foundation and a step towards answering these complex questions in a comparable and meaningful way.