Robert Ackatia-Armah

Background: This paper documents implementation lessons from a trial evaluating locally sourced food vouchers and unrestricted cash transfers for the management of moderate acute malnutrition (MAM) among children aged 6–59 months and pregnant and breastfeeding women (PBW) in Ethiopia. Methods: Implementation lessons were synthesized from program documentation, routine monitoring data, supportive supervision reports, field observations, and complementary qualitative and operational studies conducted throughout the trial. Findings were examined to identify implementation bottlenecks, adaptations, and lessons across different levels. Results: The trial enrolled a total of 6636 participants across 102 health-post clusters, comprising 3296 children aged 6–59 months and 3340 pregnant and breastfeeding women. Voucher redemption and cash collection rates ranged from 70.2% to 88.6% across the two market-based modalities, indicating generally high transfer access, although incomplete redemption or collection remained, particularly in the cash arm. The modalities were implemented in purposively selected settings with functional markets and access to financial and digital infrastructure, supported by substantial trial-specific implementation inputs. Locally sourced food vouchers enabled households to access a defined nutritious food basket adapted to local food availability but required continuous market monitoring, retailer engagement, and adherence to basket specifications. Unrestricted cash transfers provided greater household choice and purchasing flexibility but were influenced by market conditions, price fluctuations, payment processes, and intra-household decision-making. Implementation bottlenecks included frontline health worker workload and turnover, digital system delays, shortages of cash and voucher cards, retailer non-compliance, financial service delivery challenges, and household barriers such as long travel distances, limited storage capacity, and intra-household food sharing. Adaptive management included refresher training and supportive supervision, strengthened coordination with digital and financial service providers, improved supply planning, enhanced retailer monitoring, and targeted social and behavior change communication. Conclusions: The implementation experience suggests that market-based modalities can be delivered through routine health-system structures when adequate market, digital, financial, and implementation capacity is available. However, these findings are based on purposively selected study settings and substantial implementation support and should not be interpreted as evidence of feasibility or sustainability at scale. Phased and context-specific scale-up is recommended, accompanied by continued assessment under routine program conditions and across settings with varying levels of market and health-system capacity.

Existing studies focus on moderate acute malnutrition (MAM) management, with little attention to integrating MAM services into the health system. This study examines barriers and facilitators to integrating m (MAM) services into primary health care. We conducted a qualitative exploratory study at the policy, primary health care, and community levels in six regions of Ethiopia. We used the Consolidated Framework for Implementation Research (CFIR) to guide the development of the data collection tools and the analysis and presentation of the findings. We purposively selected participants and conducted in-depth interviews with 128 participants at the national, regional, district, and facility levels. Hybrid deductive-inductive analysis analysis was applied and the analysis was conducted using NVivo software version 14. Ratings were used to understand how strongly the constructs facilitated or hindered MAM integration, and patterns across levels were compared using heat maps. Integrating MAM management into the health system was considered useful and feasible, with a reliable and adaptable system in place. However, the absence of a dedicated government budget for supply chains, transport and storage services, and supervision creates heavy reliance on external donor funding, undermining government ownership. At the primary care level, understaffing and extensive paperwork and documentation requirements reduce self-efficacy and contribute to inconsistent implementation. These challenges are further compounded by community-level pressures, including misconceptions that the targeted medical supplement is a general food distribution, which increases demand beyond eligibility criteria. Additionally, access barriers such as distance, mobility constraints, and seasonal conditions, along with household dynamics such as sharing of supplements, affect utilization. Integrating MAM management into routine primary healthcare is perceived as valuable and adaptable, with support from existing policies. However, successful and sustained implementation remains constrained by context-specific health system challenges.

Background: This paper documents implementation lessons from a trial evaluating locally sourced food vouchers and cash transfers for the management of moderate acute malnutrition (MAM) among children aged 6–59 months and pregnant and breastfeeding women in Ethiopia. Methods: Lessons were synthesized from program documentation, routine monitoring data, supportive supervision reports, field observations, and complementary studies conducted throughout the trial. Results: Implementation experience demonstrated that market-based nutrition approaches can be integrated into routine health systems with systematic program preparation, market feasibility assessments, digital and financial systems, and continuous implementation support. Locally sourced food vouchers enabled households to access a defined nutritious food basket while adapting to local food availability, although maintaining program quality required market monitoring, retailer engagement, and compliance with basket specifications. Cash transfers provided greater household choice and purchasing flexibility but were influenced by market conditions, price fluctuations, household preferences, and intra-household decision-making. Implementation encountered several operational bottlenecks, including frontline health worker workload and turnover, digital system delays, cash and voucher card supply challenges, retailer non-compliance, financial service provider payment issues, and household-level barriers such as long travel distances and intra-household food sharing. Adaptive management approaches were used throughout implementation, including refresher training and supportive supervision for Health Extension Workers (HEWs), strengthened coordination with digital and financial service providers, improved supply planning, enhanced retailer monitoring through local market support groups, and targeted nutrition counseling to support appropriate use of interventions. Conclusions: Overall, the trial demonstrated that market and digitally enabled nutrition interventions are feasible alternatives for MAM management when supported by strong implementation systems. Successful scale-up requires investment in frontline workforce capacity, reliable digital and logistical support systems, effective market governance, and social and behavior change approaches that address household realities, including food access, storage capacity, and intra-household decision-making.

Food voucher and cash transfer approaches have gained attention as potential treatment strategies for managing moderate acute malnutrition (MAM); however, their effectiveness depends on caregivers’ adherence to the intended use of these approaches, including redeeming vouchers for recommended food items, using cash transfers to purchase recommended nutritious foods, and ultimately ensuring that the target child adequately consumes the foods. This study, embedded within a cluster-randomized controlled trial, assessed adherence to these treatment approaches among 1,982 children (voucher: 954; cash: 1,028). Data were collected using a structured adherence assessment tool and program records. Adherence to child food consumption was assessed using caregiver-reported information on the child’s consumption of provided foods and household food-sharing practices and was categorized into high, moderate, and low adherence levels. We found that, in the voucher group, 62.6% of children had high adherence, 23.8% moderate adherence, and 13.6% low adherence. In the cash group, 58.2% had high adherence, 18.1% moderate adherence, and 23.7% low adherence. Overall, the voucher group had a higher proportion of children with high adherence and a lower proportion with low adherence compared with the cash group. In addition, we found that both common and arm-specific factors were associated with food-consumption adherence in the voucher and cash arms. In both arms, household food security and adequate SBCC exposure were positively associated with high adherence. Compared with children from severely food-insecure households, those from food-secure households had higher odds of high adherence in the voucher (COR = 2.21, 95% CI: 1.43–3.42) and cash (AOR = 5.91, 95% CI: 3.72–9.37) arms. Adequate SBCC exposure was also associated with higher adherence in the voucher (AOR = 1.68, 95% CI: 1.26–2.23) and cash (AOR = 1.77, 95% CI: 1.32–2.39) arms. In contrast, higher household wealth was associated with lower odds of high adherence in both the voucher (AOR = 0.54, 95% CI: 0.39–0.73) and cash (AOR = 0.71, 95% CI: 0.53–0.96) arms. However, household size was associated with adherence only in the cash arm. Overall, the findings indicate that adherence to voucher- and cash-based treatment approaches is influenced by household food security, caregiver exposure to SBCC, and household characteristics. Strengthening SBCC, providing targeted caregiver support, and addressing household-level barriers may improve the appropriate use and enhance the potential effectiveness of the approaches for managing MAM.