national monthly minimum cost of a staple-adjusted, locally available nutritious diet is about PKR 2,200 per capita (or US$22). Jayasinghe, Crosby, and Hypher (2012) report that the average income of very poor households in Pakistan covers one-third of the estimated minimum cost of a locally available nutritious diet. Given this, cash transfers could improve child nutrition outcomes by raising household income.

Comparing households just below and just above a Proxy Means Targeting (PMT) cutoff for BISP transfer eligibility, under a fuzzy regression discontinuity design, Oxford Policy Management [OPM] (2016) examines the effects of BISP transfers roughly four years after the program was implemented on the ground. Over the evaluation period, the monthly household transfer amount increased from PKR 1,000 to PRK 1,200 to PKR 1,500. These amounts are equal to about 60% to 90% of average national per-capita household consumption spending for below-PMT households at baseline. And they are equal to about 50% to 70% of average national per-capita minimum cost for a staple-adjusted, locally available nutritious diet, using the minimum-cost-of-diet statistics presented earlier. The study finds that, while the actual transfers saw some delays and shortfalls, they have a significant positive effect on total and nonfood household spending, and a significant positive effect on household spending on meat and fish; however, the study does not find a robust significant positive effect on household food spending in general. The study also finds that the transfers have a significant negative effect on the wasting rate for girls, of –11 percentage points, but an insignificant positive effect for boys; and insignificant effects on stunting, underweight, full immunization, and diarrhea for boys or girls.<sup>44</sup> The study did not attempt to explain the pattern of results across the different outcomes, or for girls versus boys.

In another study of the effects of BISP, using propensity score matching, Nayab and Farooq (2014) find that households that received cash transfers through the program have higher food and health spending than households that did not receive transfers. However, the study does not evaluate the effects of the cash transfers on nutrition outcomes. We did not find any empirical evidence on the effects of Guzara allowances or Pakistan Bait-ul-Mal transfers on child nutrition status or other potentially related outcomes.<sup>45</sup>

- C. _Public primary health system_

> 44 Given that the results are valid for a particular set of households near the PMT cutoff, these households are initially better off than all households below the PMT cutoff.

> 45 School-based feeding or food-for-education programs can be conceived to be a conditional in-kind transfer program (Ruel et al. 2013). The direct beneficiaries of school-based feeding programs are not children under five years of age, the age group of interest in this review. However, international evidence indicates that these programs can influence the nutrition status of school-going children, and that they can indirectly influence the nutrition status of younger siblings of school-going children (Singh, Park, and Dercon 2014; Alderman and Bundy 2011; Jomaa, McDonnell, and Probart 2011; Afridi 2010; Adelman et al. 2008; Kristjansson et al. 2007; Coly et al. 2006; Ahmed 2004). These programs may also improve the health and nutrition status of children subsequently born to beneficiary girls. Two studies for Pakistan employ a before-after comparison design to evaluate the effects of a pilot feeding intervention for female public primary school students under the Tawana Pakistan project, which was administered by the government in partnership with NGOs and local communities. Food was locally sourced, and community women were responsible for carrying out ground operations. The studies find significant, large negative effects on underweight and wasting status, but an insignificant effect on stunting status of school-going children (Hussain et al. 2013; Badruddin et al. 2008).

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