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

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 MDMS69 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

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.