**Background:** Maternal and early childhood malnutrition has lifelong negative impacts on health and human development. While early nutrition interventions can protect developmental potential, their benefits depend on the later-life environment—including access to schooling and employment opportunities. In fragile states with high inequality, siloed nutrition investments may yield uneven returns and even exacerbate disparities. This study examines the limits of nutrition-only investments in Burkina Faso, a country with high malnutrition and state fragility, and explores whether adding a cash transfer in later childhood can improve outcomes and reduce inequality.
**Methods:** The authors modelled the impact of scaling up 10 nutrition-specific interventions (folic acid fortification, multiple micronutrient, calcium and balanced energy protein supplementation in pregnancy, exclusive breastfeeding promotion, complementary feeding, vitamin A and zinc supplementation, and management of severe and moderate acute malnutrition) from current coverage to 80% for a single-year birth cohort. The Lives Saved Tool (LiST) was used to estimate changes in stunting (HAZ < -2) nationally and in three regions: Centre (most stable and prosperous), Nord (poorest), and Sahel (most conflict-affected). The change in stunting was converted to a shift in mean z-score, which was then linked to years of schooling (0.48 additional years per standard deviation improvement in z-score) and adult earnings. Three scenarios were modelled: (1) baseline (current coverage, no cash transfer); (2) nutrition scale-up alone; (3) nutrition scale-up plus a conditional cash transfer (US$18–32 per year, based on the Nahouri Cash Transfers Pilot Project) that reduces school dropout by 30%. Costs included intervention delivery costs plus transport vouchers for geographic access barriers. Productivity returns were calculated as the present value of increased lifetime income and compared to intervention costs.
**Key Results:** Scaling nutrition interventions to 80% coverage reduced national stunting from 25.76% to 22.98% (a 2.78 percentage point reduction), with a mean z-score shift of 0.0887. Regional stunting reductions were: Centre from 12.90% to 11.26% (z-score shift 0.0817), Nord from 28.24% to 25.26% (shift 0.0906), and Sahel from 44.62% to 40.77% (shift 0.0982). The present value of increased lifetime earnings from nutrition alone was $54.3 million nationally ($69 per child), ranging from $104 per child in Centre to $26 per child in Sahel. The cost-benefit ratio for nutrition alone was 1:1 nationally, 1:2 in Centre, 1:1 in Nord, and less than 1:0.2 in Sahel. With the addition of cash transfers, the present value of increased earnings rose to $1.57 billion nationally ($2,009 per child), with per-child benefits of $2,146 in Centre, $1,585 in Nord, and $285 in Sahel. The combined cost-benefit ratio was 1:12 nationally, 1:11 in Centre, 1:8 in Nord, and 1:1 in Sahel. The nutrition interventions alone were estimated to save 32,452 additional lives among children 0–59 months.
**Clinical Implications:** This study demonstrates that early nutrition interventions alone, while beneficial, generate highly unequal returns across regions in fragile contexts—with the worst-off regions receiving the smallest benefits despite having the greatest need. This pattern risks reinforcing existing inequalities that contribute to state fragility. Adding complementary interventions like cash transfers can substantially improve both the magnitude and equity of returns, though the Sahel region still lags significantly, indicating that multiple complementary investments may be needed. The findings underscore the importance of taking a life-course perspective in priority-setting: interventions that protect human development potential must be paired with those that enable its realization (e.g., schooling) and utilization (e.g., employment opportunities). For clinicians and policymakers, this means that nutrition programs in fragile settings should not be implemented in isolation but as part of integrated packages that address later-life constraints, and that equity-focused evaluation is essential to avoid inadvertently widening disparities.