Impact of the mid-day meal scheme in IndiaS Karande1, NJ Gogtay2
1 Department of Pediatrics, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Parel, Mumbai, Maharashtra, India
2 Department of Clinical Pharmacology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Parel, Mumbai, Maharashtra, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0022-3859.132302
Source of Support: None, Conflict of Interest: None
The concept of serving school children a mid-day meal to allay classroom hunger, enhancing school enrollment and attendance and simultaneously improving nutritional levels among school children is not new in India.  In 1925, the British administration initiated a mid-day meal scheme (MDMS) for disadvantaged children in Madras Municipal Corporation.  In 1962, the state government of Tamil Nadu introduced a MDMS in primary schools in Chennai and later extended it to all districts of Tamil Nadu.  In 1984, the scheme was introduced in the state of Gujarat. 
On 15 th August 1995, the Government of India (GOI) launched the MDMS as a national program and named this program as the National Program of Nutritional Support to Primary Education (NP-NSPE).  Under this scheme all primary school children (classes I-V) attending government and government-aided schools were to be provided free supply of 100 grams food grains per school day.  The mid-day meal aimed to daily provide at least one-third of recommended calories and half of the proteins to every beneficiary.  Alleviation of classroom hunger was also aimed at improving academic achievement in undernourished school children.  This objective was based on Simeon's postulation that school feeding leads to short-term rises in blood glucose levels (and hence brain) , which counteracts the negative effect of classroom hunger on concentration, memory and motivation, which are fundamentals for learning. 
In 2001, the Hon. Supreme Court of India ordered the GOI that the NP-NSPE should provide 'cooked meals' with a minimum nutritive content of 300 calories and 8-12 gms of proteins for each day of school for a minimum of 200 days.  In 2006, the GOI revised the nutritional norm to 450 calories and 12 gms of proteins. In 2007, the GOI extended the scheme to cover children of upper primary classes (i.e. class VI to VIII) and changed its name to 'National Program of Mid Day Meal in Schools' (NP-MDMS).  The nutritional norm for upper primary stage has now been fixed at 700 calories and 20 grams of protein. 
Since 2008, the NP-MDMS has been implemented across the country.  Currently, India's NP-MDMS is the largest nutritional program for school children in the world, covering 104.4 million children in 1.2 million schools across the country with an annual budget allocation of Rupees 119,370 million.  The Office of the Supreme Court Commissioners has observed that the NP-MDMS is one of the more successful entitlement schemes of the GOI and has resulted in an increase in enrollment, attendance and retention of children in primary schools.  It has also helped foster social equality and enhanced gender equity as more parents are now sending their daughters to school. 
The GOI has instituted an ongoing inbuilt monitoring mechanism to ensure that the NP-MDMS runs smoothly. 
At each school level, local committees are required to monitor the scheme on a daily basis; namely: (i) regularity and wholesomeness of the meal served to children, (ii) cleanliness in cooking and serving of the meal, (iii) timeliness in obtaining of good quality ingredients, fuel, (iv) implementation of varied menu, and (v) social and gender equity.  In order to ensure that there is transparency and accountability every school has to display all information related to implementation of the scheme. State Government officials are also required to inspect schools. The Food Corporation of India has been given the responsibility to ensure the continuous availability of adequate and good quality food grains. The State Governments are required to submit periodic returns to the GOI. Forty-one Institutions of Social Science Research have also been entrusted the on-going task to monitor the NP-MDMS. 
Before the launch of the NP-NSPE in 1995 it was ethically possible to do case-control studies to monitor the impact of the mid-day meal. Agarwal et al.  studied the effect of the mid-day meal in rural primary school children (aged 6 to 8 years) near Varanasi, in the state of Uttar Pradesh over the period of 2 years (1984-1986). As compared to controls, in the study group there was a significant improvement in school attendance and reduced dropout rate, but only a marginal improvement in cognitive functioning. Also, significantly less children in the study group progressed to grade II stage of malnourishment as compared to controls. However, there was no significant difference in annual height gain in the two groups.  Agarwal et al.  have explained the less than optimal impact on weight in the study group with the assumption that probably their parents provided them with less food at home (as they had already received a meal at school). The children being in pre-pubertal stage (which by itself is a slow growth in height period) has been stated as the possible reason for the less than optimal impact on height. 
Laxmaiah et al.  studied the effect of the mid-day meal in the Kolar and Mysore districts of the state of Karnataka over 2 years (1992-1993). As compared to controls, in their study group there was significantly better school enrolment and attendance; and a reduced dropout rate.  However, there was only a marginal improvement in school performance and nutritional status.  In 1994,the state of Gujarat introduced an anthelmintic drug plus micronutrients "health package" along with the mid-day meal.  This "health package" consisted of a single dose of albendazole (400 mg) and vitamin A tablets (200,000 IU); and iron tablets (20 to 60 mg elemental iron) delivered twice a week at the beginning of each school term.  Gopaldas  has evaluated this improved scheme and reported that school children (aged 6 to 15 years) who received this health package along with the mid-day meal were on an average 1.1 kg heavier and 1.1 cm taller than those who did not receive a mid-day meal + health package. The study children also had significantly lower prevalence of anemia, intestinal parasites and vitamin A deficiency. 
Sharma et al.  have compared the impact of a wholesome mid-day meal provided by a non- government organization (NGO) with that provided by village panchayats on the growth and nutritional status of primary school students (aged 5 to 12 years) in rural area of Mathura district, in the state of Uttar Pradesh (from 2006 to 2007). They have reported a significant (and equivalent) improvement in height and weight in both groups after one year. However, only the mid-day meal provided by the NGO significantly reduced prevalence of vitamin A and D deficiencies. 
In the current issue, Shalini CN and colleagues  have compared the nutritional status of rural and urban school students (aged 5 to 15 years) receiving mid-day meals prepared by the Sri Sai Mandali Trust in schools of Bengaluru, India. They have reported that in spite of the children receiving mid-day meals their observed weight and height in both groups were below the expected standards.  Shalini et al.  have concluded that the mid-day meal did have a positive impact as the number and the degree of malnourishment would have been much greater in the absence of the scheme.  The authors however have missed an opportunity to evaluate whether the meals have impacted school attendance, school drop-out rate and academic performance of children in both groups. They could have also conducted focused group discussions with the school teachers and cooks to know whether the scheme has impacted social and gender equality and whether the children find the meals to be palatable or not.
The World Food Program has called on all leaders to support universal school feeding for world's poor children as classroom hunger is immediately alleviated, and school attendance often doubles within one year.  Recent Cochrane  and BMJ  reviews (which included 18 trials from five continents reported over the last eight decades) has found that school feeding programs in disadvantaged children significantly improve school attendance levels and the growth and cognitive performance of disadvantaged children. Currently, school feeding programs (either as a breakfast or lunch) are being implemented worldwide in 169 countries (both in developing and affluent countries), and up to 368 million children are being fed daily; with up to US$75 billion invested each year.  Unfortunately, in low-income countries, where the need is greatest, the overall average coverage is the lowest (18%); and in lower-middle-income countries it is 49% with India at 79%.  School-feeding programs achieve much more than just feeding children. They contribute to a child's readiness to learn and ability to participate in his or her own educational process, and the benefits are particularly strong for girls.  Along with "quality education", it promotes human capital development in the long run and helps break inter-generational cycles of poverty and hunger. 
Even in affluent countries school feeding programs play an important role to enhance the diet and health of school children. ,, These affluent school children are being given a daily balanced diet of fruits, vegetables, whole grains, and low-fat dairy products as a strategy to promote healthy eating behaviors and help mitigate the childhood obesity trend due to rampant intake of "junk food". ,,
Since the 1970s, our country has become self-sufficient in food production.  Unfortunately, since then the reduction in under-nutrition in children is only 20%; and currently 42.5% of under-5 children remain undernourished.  This high under-nutrition rates among Indian children appears to be mainly due to high low birth weight rates (30%), poor infant and young child feeding and caring practices.  The beneficiaries of the GOI's Integrated Child Development Services (ICDS) scheme include under-6 year old children, pregnant and lactating mothers, and other women in the age group of 15 to 44 years. The package of services provided by the ICDS scheme includes supplementary nutrition, immunization, health check-up, referral services, nutrition and health education, and pre-school education. 
To improve the nutritional quantity and quality of the NP-MDMS, Deodhar et al.  have recommended that, in addition to the mid-day meal, school children should also receive sukhdi or chikki or a nutritional food bar twice a week and a seasonal fruit (usually banana as it is the cheapest) once a week. Also, there has been a plea to extend the NP-MDMS to secondary and higher secondary school-going children (up to class XII).  In recent times, there have been some tragic incidents with respect to this program.  In the wake of these incidents, the GOI has decided to constitute a monitoring committee to look into the quality of food supplied and ensure effectiveness of the supply chain and proper hygiene. This committee is expected to supplement the efforts of the existing Mid-Day Meal monitoring committee which meets twice a year and warns the states if there are any short comings.  The GOI has also asked all states to set up decentralized monitoring units, increase public awareness about the mid-day meal so that parents can keep a watch, and to set up monthly monitoring by a community committee headed by the local Member of Parliament. The Ministry has issued guidelines to all states to ensure quality, safety and hygiene under the NP-MDMS. Aside from making it mandatory for a teacher to taste the food before serving it to the school children, the GOI has asked that a member of the school management committee to be present and taste the meal.  Stressing on the need for safety and hygiene, the Ministry has asked all states to use the recommended kitchen-cum store designs. An on-line review system for the NP-MDMS has also been initiated.  This web-enabled management information system with interactive voice response system will ensure that all states submit monthly reports to the GOI on time. It will also provide instant data relating to number of children covered, food grains procured, utilized, non-provision of meals in schools and irregularities, if any. 
Since 1 st April 2010, the GOI has implemented the Right of Children to Free and Compulsory Education Act, 2009 (RTE Act).  This Act makes education free and compulsory to all children of India in the 6-14 years age group, and has initiated steps to ensure that school children receive "quality education".  It is envisioned that the proper implementation of the GOI's ICDS scheme, NP-MDMS and RTE Act in combination will result in all Indian children being well-nourished and well-educated. Eventually, these healthy and well-educated citizens will ensure a brighter future for our country.
The authors thank the Dean, Seth GS Medical College & KEM Hospital, for granting them permission to publish this manuscript.