The benefits of interventions which improve early nutrition are well recognised. These benefits, however, only accrue to the extent that later life circumstances allow. Consequently, in adverse contexts many of the benefits will never be realised, particularly for the most vulnerable, exacerbating inequality. Returns to investment in early nutrition could be improved if we identified contextual factors constraining their realisation and interventions to weaken these. We estimate cost and impact of scaling 10 nutrition interventions for a cohort of South African children born in 2021. We estimate associated declines in malnutrition and mortality, and improvements in years of schooling and future earnings. To examine the role of context over the life-course we estimate benefits with and without additional improvements in school quality and employment opportunities by socio-economic quintile. Scale up reduces national stunting (height for age < = -2SD) rates among children at 24 months by 3.18 percentage points, implying an increase in mean height for age z-score (HAZ) of 0.10, and 53,000 years of additional schooling. Quintile 1 (the poorest) displays the largest decline in stunting, and largest increase in mean HAZ. Estimated total cost of increasing coverage of the interventions for the cohort is US$90 million. The present value of the additional years of schooling is estimated at close to US$2 billion. Cost-benefit ratios suggest the highest return occurs in quintile 5 (1:23). Reducing inequality in school quality closes the gap between quintile 5 and the lower quintiles. If school quality and labour force participation were equal the highest returns are in quintile 1(1:31). An enabling environment is key to maximising human development returns from investing in early nutrition, and to avoid exacerbating existing inequality. Therefore, particularly for children in adverse conditions, it is essential to identify and implement complementary interventions over the life course.

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Maternal and early malnutrition have negative health and developmental impacts over the life-course. Consequently, early nutrition support can provide significant benefits into later life, provided the later life contexts allow. This study examines the limits of siloed investments in nutrition and illustrates how ignoring life-course contextual constraints limits human development benefits and exacerbates inequality, particularly in fragile contexts. This case study focuses on Burkina Faso, a country with high rates of early malnutrition and a fragile state. We modelled the impact of scaling up 10 nutrition interventions to 80% coverage for a single year cohort on stunting, nationally and sub-nationally, using the Lives Saved Tool (LiST), and the consequent impact on earnings, without and with a complementary cash-transfer in later life. The impact on earnings was modelled utilising the well-established pathway between early nutrition, years of completed schooling and, consequent adult earnings. Productivity returns were estimated as the present value of increased income over individuals’ working lives, then compared to estimates of the present value of providing the cost of nutrition interventions and cash-transfers. The cost benefit ratio at the national level for scaled nutrition alone is 1:1. Sub-nationally the worst-off region yields the lowest ratio < 0.2 for every dollar spent. The combination of nutrition and cash-transfers national cost benefit is 1:12, still with regional variation but with great improvement in the poorest region. This study shows that early nutrition support alone may not be enough to address inequality and may add to state fragility. Taking a life-course perspective when priority-setting in contexts with multiple constraints on development can help to identify interventions that maximizing returns, without worsening inequality.

MotivationInvesting in girls’ schooling in low‐ and middle‐income countries (LMICs) is seen as central to improving gender equity. It is argued that interventions to promote girls’ enrolment are appropriate as girls face gendered barriers to school enrolment and completion and investing in girls’ schooling has high economic and human‐development returns. But is this fair to boys and enough for girls?PurposeWe ask how appropriate it is to direct development assistance towards improving girls’ school enrolment, compared to prioritizing schooling for both girls and boys, and addressing barriers to gender equality throughout the life‐course.Methods and approachWe frame the enquiry through a human development framework with three distinct but interdependent domains: protection of human development potential; realization of human development potential; and use of human development potential.Using publicly available data, we identify indicators likely to be correlated with the degree to which human development potential is protected, realized, and utilized in LMICs. We compare male and female outcomes on each of these indicators to assess gender parity at different life stages.FindingsIn most regions, girls are ahead of boys in both school enrolment and completion. Girls have better outcomes than boys in several other indicators in early life and childhood.In adolescence and adulthood girls and women fall behind boys and men. This is especially apparent in workforce participation, in unemployment, in pay, and in share of unpaid care work and political participation where women have less favourable outcomes than men. The bias against women is most marked in South Asia and sub‐Saharan Africa.Policy implicationsA focus on girls’ schooling should be tempered by ensuring quality pre‐primary, primary, and secondary schooling for both boys and girls. Simultaneously we must address causes of gender inequality, including labour market discrimination and social norms which justify the exclusion and exploitation of women and girls.

As any caregiver will attest, understanding the needs of your child is a complicated business. Understanding the varied needs of a population of children with whom you have no direct contact is near impossible, yet it is the challenge policy makers, government planners and donors face when making policy or selecting interventions to fund and implement. They cannot unpack each child's individual needs and so must predict what is most important for a given population and which services should therefore be prioritised. Priority setting can be simplified by assuming that the needs of other people's children are hierarchical. If needs are hierarchical, basic needs, such as food and shelter, must be met before it is possible or necessary to consider higher order needs, such as belonging and self-actualisation. This conceptualisation justifies a focus on basic needs and decision makers can ignore higher order needs and the complex interventions they may require, because both are assumed to be of secondary importance. We suggest that assuming needs are hierarchical and thus focusing on basic needs is a mistake. By drawing on examples from the literature, we outline how children, our own and other people's, have non-hierarchical needs thus caring for them is a balancing act, best done by those close to them. This conceptualisation of need highlights the importance of families and therefore how policy makers wishing to support children with whom they are not in close contact should focus on creating an enabling environment for families. For a subset of families who are struggling, additional family strengthening interventions may be needed. In the relatively rare cases that such interventions are insufficient as family function is severely compromised, more intensive interventions may be necessary, but must be undertaken with great care and skill. Social services are critical because they have a potential role along the continuum of need, from initial identification of problems, to service access and then direct support. They have the potential to facilitate the intensive interventions when they are required, and while they are not required by all, for some of the most vulnerable children they are essential. The quality standards of such a service will be key in meeting the needs of other people's children.

INTRODUCTIONThis paper outlines the protocol, history, and scope of the Asenze Cohort Study in KwaZulu-Natal, South Africa. South Africa is a middle-income country shaped by the legacies of apartheid, periods of violent political instability, and an initial refusal of the government to acknowledge human immunodeficiency virus (HIV) as the cause of acquired immune deficiency syndrome (AIDS). These historic and ongoing challenges have led to South Africa having one of the highest prevalence rates of people living with HIV/AIDS [1] and one of the highest rates of socioeconomic inequality [2].The HIV/AIDS epidemic has increased the burden of childhood developmental disability and challenges to adolescent health and well-being in low-income and middle-income countries. HIV/AIDS is a multi-system, chronic illness whose impact on child health is physical, cognitive, and/or psychological. Children whose parent(s) are living with HIV/AIDS may be affected directly, through vertical transmission from mother to child, or indirectly, due to comorbidities or early mortality of a caregiver, which may in turn impact the quality of child care. HIV is a leading cause of disability across South Africa, including KwaZulu-Natal, the province with the highest prevalence of HIV [3]. Given HIV's im-The Asenze cohort is set in South Africa, a middle-income country impacted by one of the highest global rates of people living with HIV/AIDS and high levels of socioeconomic inequality. This longitudinal population-based cohort of children and their primary caregivers assesses household and caregiver functioning, child health, social well-being, and neuro-development from childhood through adolescence. Almost 1,600 children born at the peak of the human immunodeficiency virus epidemic (2003)(2004)(2005) were followed (with their primary caregivers) in 3 waves, between 2008 and 2021, at average ages of 5, 7, and 16. Wave 3 is currently underway, having assessed over 1,100 of the original wave 1 children. Wave 4 begins in 2022. The study, with a dyadic structure, uses a broad range of measures, validated in South Africa or recommended for global use, that address physical, social and neuro-development in childhood and adolescence, and the social, health, and psychological status of children's primary caregivers. The Asenze study deepens our understanding of childhood physical, cognitive, and social abilities and/or disabilities, including risk-taking behaviors, and biological, environmental, and social determinants of health. We anticipate the findings will contribute to the development of community-informed interventions to promote well-being in this South African population and elsewhere.

The Covid-19 pandemic and resultant disruptions to schooling presented significant challenges for many families. Well organised families have been shown to have a protective effect on adolescent wellbeing in periods of shock. At the onset of the Covid-19 pandemic, Asenze, a population-based cohort study, was conducting a third wave of data collection in peri-urban South Africa, examining risk and protective factors during adolescence. By March 2020, n = 272 adolescents and their caregivers (n = 241) in the cohort had been assessed when in-person data collection was halted by lockdown measures countrywide. During this cessation we undertook a brief telephonic qualitative sub-study to explore whether families enrolled in the cohort were able to cohabit cohesively and undertake distance learning during lockdown. A purposeful sample of 20 families (caregivers n = 20, adolescents n = 24) recently assessed in the Wave 3 of the main study, participated in semi-structured interviews. Quantitative data from Waves 1–3 of the main study was used to measure family function, adolescent cognitive function, and profile adolescent and caregivers. The quantitative and qualitative data were integrated to illustrate the dynamics of the participants’ lives before and during lockdown. We found that families classified as well-organized before lockdown, were more likely to report co-operation during lockdown. Adolescents who were self-motivated, had access to smartphones or the internet, and were supported by both family and educators, were well-placed to continue their education without much disruption. However, few schools instituted distance learning. Of the adolescents who were not assisted- some studied on their own or with peers, but others did no schoolwork, hindered by a lack of digital connectivity, and poor service delivery. The experience of adolescence and caregivers in the Asenze Cohort during lockdown highlight the importance of family functioning for adolescent wellbeing in crisis, as well as the need for access to health, mental health, and social services, communication upgrades, and enhancements to the education system during peaceful times, to make a difference to young lives in times of crisis.