Medium‐Run Impacts of Iron‐Fortified School Lunch on Anaemia, Cognition, and Learning Outcomes in India*
| Published date | 01 December 2023 |
| Author | Liza von Grafenstein,Abhijeet Kumar,Santosh Kumar,Sebastian Vollmer |
| Date | 01 December 2023 |
| DOI | http://doi.org/10.1111/obes.12559 |
OXFORD BULLETIN OF ECONOMICS AND STATISTICS, 85, 6 (2023) 0305-9049
doi: 10.1111/obes.12559
Medium-Run Impacts of Iron-Fortified School Lunch
on Anaemia, Cognition, and Learning Outcomes
in India*
LIZA VON GRAFENSTEIN,†,‡ ABHIJEET KUMAR,§ SANTOSH KUMAR¶,#
and SEBASTIAN VOLLMER††,§
†Department of Agricultural Economics and Rural Development, University of Goettingen, Platz
der G¨
ottinger Sieben 5, 37073, G¨
ottingen, Germany(e-mail: liza.grafenstein@uni-goettingen.de)
‡IDinsight India Private Limited, New Delhi, India
§Centre for Modern Indian Studies, University of Goettingen, G¨
ottingen, Germany(e-mail:
abhijeet.kumar@cemis.uni-goettingen.de)
¶Keough School of Global Affairs & Eck Institute for Global Health, University of Notre Dame,
Notre Dame, Indiana, 46556, USA(e-mail: skumar23@nd.edu)
#IZA, Bonn, Germany
††Department of Economics, University of Goettingen, G¨
ottingen, Germany(e-mail:
svollmer@uni-goettingen.de)
Abstract
Using a phase-in research design, we provide experimental evidence on the impacts
of early versus late initiation of iron fortification in school lunch programmes on
children’s health and cognitive outcomes in India. We find higher haemoglobin levels
and a lower likelihood of anaemia in the early treatment group that experienced 4years
of treatment, compared to the late treatment group that was exposed to one and a
half years of treatment. Despite significant health gains, we do not find evidence for
treatment effects on cognitive and educational outcomes. Heterogeneity analyses show
evidence of gendered effects –the anaemia reduction is lower among females relative
to males.
JEL Classification numbers: C93, I15, I18, O10.
*This study is registered in the AEA RCT Registry with the unique identifying number: ‘AEARCTR-0006800’.
We thank the editor Climent Quintana-Domeque and three anonymous referees for their constructive suggestions.
An earlier version of this manuscript was titled ‘Impacts of Double-Fortified Salt on Anemia and Cognition:
Four-Year Follow up Evidence from a School-Based Nutrition Intervention in India’. The current version
supersedes all previous versions. We are grateful to John Hoddinott, late Prof. Stephan Klasen, Christina Martini,
and Meike Wollni for feedback on earlier versions of this paper. We thank Bianca D¨
ulken, Thea Eyting, Lena
Gempke, Dara Krolpfeifer, Maximilian K¨
oster, Tabea Recksiek, and Carmen Steinmetz for excellent research
assistance. We thank conference participants atNEUDC 2020, NCDE 2021, DGG ¨
O 2021, GLAD 2021, ACEGD
2021, University of Notre Dame, and ANH Academy Week 2022 as well as participants and discussants in the
GlobalFood Research Colloquium at Georg August University of G¨
ottingen, the International Nutrition Seminar
at Cornell University, and the Kyoto Environment & Development Seminar at Kyoto University for valuable
feedback. We thank Professor Dr. Claudia M¨
ahler for her collaboration regarding cognitive ability tests. This
1262
©2023 The Authors. Oxford Bulletin of Economics and Statistics published by Oxford University and John Wiley & Sons Ltd.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and
distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Medium-run impacts of iron-fortified school lunch in India1263
I. Introduction
Micronutrient deficiencies, particularly iron deficiency anaemia (IDA), are a significant
global health concern in many developing countries, impacting children’s physical
and cognitive development. More than one-half of preschool-aged children and
two-thirds of non-pregnant women of reproductive age suffer from micronutrient
deficiencies (Stevens et al.,2022). IDA can lead to poor cognitive function, growth
impairment, and lower human capital, which can have long-term implications for
individuals and societies, such as lower household per capita expenditure and a higher
probability of living in poverty as an adult (Dasgupta and Ray, 1986; Strauss and
Thomas, 1998;Alderman,2006; Hoddinott et al.,2013). There is a strong causal
association between IDA and educational outcomes, including grades, attendance,
and educational attainment (Halterman et al.,2001; Bobonis, Miguel, and Puri-
Sharma, 2006; Chong et al.,2016;Liet al.,2018).1Therefore, addressing IDA is
of particular interest to policymakers, as it has the potential to improve human capital
and subsequently contribute to the economic development and growth of less-developed
economies.
Efficacy studies conducted in a controlled environment show significant impacts
of double-fortified salt (DFS) on anaemia (Ramirez-Luzuriaga et al.,2018; Larson
et al.,2021). Yet, a large-scale DFS programme has shown limited impacts on
anaemia in developing countries (Banerjee, Barnhardt, and Duflo, 2018). Additionally,
a handful of studies evaluate the impacts of DFS and iron supplementation
pills and find limited short-term impacts of these interventions on anaemia and
cognition (Chong et al.,2016; Banerjee et al.,2018;Kr
¨
amer, Kumar, and
Vollmer (2021a).2
Kr¨
amer, Kumar, and Vollmer (2021a), hereafter KKV, show that a school-based
DFS intervention in India significantly reduced anaemia but had no impact on cognitive
outcomes after 1 year of treatment. It is of further interest whether the short-run health
gains persist or wane over time and whether longer treatment duration increases the
magnitude of the programme impacts, relative to shorter treatment duration. Furthermore,
several studies show programme impacts in the medium- and long-run even when there
are no impacts in the short run (Behrman, Parker, and Todd, 2011;Bairdet al.,2016;
Parker and Todd, 2017; Ozier, 2018; Bouguen et al.,2019). Therefore, it is likely that
despite null effects on cognition in the short term, continuous and sustained DFS treatment
in the medium- to long-term may affect cognition. The key objective of this study is to
work was supported by the German Research Foundation (DFG) for funding via RTG 1666 and RTG 1723
and by SWAGATA - Erasmus+Consortium of G¨
ottingen, Heidelberg, and K¨
oln Universities. Santosh Kumar
acknowledges the funding received from the Sam Houston State University Office of Research and Sponsored
Programmes.
1There are many types of anemia, but the most common type is iron-deficient anemia (IDA) –more than 50%
of anaemia cases worldwide are due to iron deficiency. Nutritional deficiencies and infectious disease burden are
the leading causes of anaemia among children globally but the predominant cause of IDA in India is a nutritional
deficiency (WHO, 2015).
2DFS is fortified with iron and iodine.
©2023 The Authors. Oxford Bulletin of Economics and Statistics published by Oxford University and John Wiley & Sons Ltd.
1264 Bulletin
estimate the medium-term impacts of DFS-fortified school lunches on anaemia, cognition,
and learning outcomes in rural parts of India.
This study is a follow-up to the KKV study and causally identifies the effect of longer
vs. shorter treatment duration of a school-based DFS intervention on children’s anaemia
status and cognition. We exploit the phase-in research design to estimate the persistence
of short-run treatment impacts in the medium term. The original control group of schools
was phased into treatment after 28 months, which created early and late treatment groups,
a randomization design similar to Miguel and Kremer (2004).3Bouguen et al. (2019)
highlight that measuring medium- or long-term programme impacts is important for
a better understanding of the underlying mechanisms of interventions. Additionally,
measuring the short-term benefits of health interventions is valuable but does not offer
much insight into the programme effects if benefits persist in the long run. Thus, the
long-term programme impacts could be relevant to the analysis of the cost-effectiveness
of the programmes.
We conducted the DFS experiment in two administrative blocks of Jehanabad district in
Bihar. Bihar is one of the poorest states in India, with a high prevalence of anaemia among
school children (World Bank, 2016; IIPS and ICF, 2017). The intervention delivered DFS
to 54 public primary and middle schools (MS) starting in 2015, while the 53 control
schools only started receiving DFS in December 2017. As the endline survey for this
study was conducted in 2019, our phase-in experimental design provides about 4 years of
treatment exposure in the early treatment schools and about one and a half years in the late
treatment schools. The panel nature of data allows us to use the double differences (DD)
method with child fixed effects to estimate the causal impacts of the DFS intervention on
children’s health, cognition, and education outcomes in the medium term.
Our results show that children in the early treatment group benefited more than
children in the late treatment group, who received the treatment for only one and a
half years. Children in the early treatment group had on average a 0.267g/dL higher
haemoglobin (Hb) level than those in the late treatment group and also a lower likelihood
of any anaemia –less than 13.4 percentage points (pp). Further, the school-based DFS
intervention decreased the incidence of mild anaemia by 10.6pp. The treatment effects
on health outcomes are non-uniform and vary by gender and school attendance rate.
However, despite significant health gains, we found no impact on the children’s cognitive
outcomes. The non-significant effect on cognition is similar to the findings in Miguel
and Kremer (2004) –the deworming health intervention found no cognitive gains after
1– 2 yearsoftreatment(MiguelandKremer,2004). We believe the null impact on
cognitive outcomes is an important finding of this paper and we discuss the possible
reasons for this in detail in the results section.
Our study makes several important contributions to the literature on the effects of
nutritional interventions on the health and cognitive outcomes of school children. First,
we provide evidence of the medium-run impact of a school-based nutritional intervention.
KKV show that the iron-fortified school lunches programme in primary school resulted
3Students in the treated schools received fortified school lunch for 32– 48months and the students in the control
schools received fortified school lunch for 4– 20months. Hence, in the absence ofa pure control group, the treatment
effect in this study is ‘the effect of more DFS or higher DFS program intensity’.
©2023 The Authors. Oxford Bulletin of Economics and Statistics published by Oxford University and John Wiley & Sons Ltd.
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