Background: The present paper concerns a cost and cost-outcome study of school meal programs. It is based on a Cochrane/Campbell review of school meals (Kristjansson, 2007), which was one of the first reviews produced by members of the Cochrane Equity Field. This review provided an opportunity to conduct a cost-outcome analysis of school feeding programs. Objectives: Our main objectives were to: (1) provide an up-todate, realistic estimate of the costs of school feeding; (2) combine these estimates with results of the Kristjansson review to estimate all the costs of school feeding programs to the World Food Program, the governments, and communities. Methods: We calculated costs for four countries: Kenya, Malawi, Lethso, and the Gambia, using a combination of World Food Program documents and interviews with WFP staff, Ministry of Education staff, and teachers (in Kenya). In order to provide a meaningful comparison, we standardized the days fed to 200 and the energy given to 700 kcal. Cost per outcome was calculated by dividing the costs per child per year in each country/region by the average gain (e.g. IQ points, days of attendance, kg of weight) per 200 day school year from the Kristjansson review. Results: Costs per child per year ranged from USD 28.00 to USD 61.00. The cost for an extra day of attendance per child ranged from USD 4.00 to USD 12.00, while the cost of an extra point on the Wide Range Achievement test ranged from USD 31.60 to USD 69.00. Conclusions: School feeding programs do improve some aspects of the health of disadvantaged children. We believe that the cost/outcome ratios can be reduced by focusing on enhancing student outcomes in ways that will lead to little cost increase and provide several suggestions for making school feeding programs more cost effective. This is particularly important in an era where world food supplies are dwindling.