Community-based approaches to combating malnutrition and poor education among girls in resource-poor settings: report of a large scale intervention in Pakistan.

INTRODUCTION Malnutrition and low levels of education continue to be major problems in many developing countries, especially for female children. METHODS In Pakistan, a large-scale school lunch program was implemented in 29 of the poorest rural districts through a public-private partnership. The project provided freshly prepared meals in 4035 government primary girls' schools over a 2 year period. The primary strategy was empowerment of women in the community who volunteered to plan the meals, purchase the food, and cook and serve the meals. The project collected data from growth monitoring, attendance records, pre- and post-intervention community based surveys, focus group discussions, and the use of other ethnographic methods. A study on changes in the levels of malnutrition was based on an analytical sample of 203,116 girls who received at least two sets of body measurements at least 6 months apart. RESULTS Over the intervention period, wasting declined by almost half and school enrolment increased by 40%. Girls who entered the program early were found to have similar levels of malnutrition to girls who entered late, suggesting that factors external to the program were not associated with the decrease in malnutrition. CONCLUSION This study demonstrates the potential success and scalability of school feeding programs in Pakistan. Lessons learned include that synergies are found when working across sectors (health, education, and empowerment) and that there are challenges to intersectoral projects. Globalization may undermine this successful model as Pakistan considers expanded school feeding programs.