Effects of unconditional cash transfers on the outcome of treatment for severe acute malnutrition (SAM): a cluster-randomised trial in the Democratic Republic of the Congo
Childhood malnutrition is a significant cause of ill health and poor development worldwide. High-quality nutrition is essential in early childhood to ensure healthy growth, proper organ formation and function, a strong immune system and neurological and cognitive development. Children with severe acute malnutrition (SAM) are at high risk of morbidity and death . There are estimated to be 19 million children younger than 5 years of age with SAM worldwide, of whom more than 800,000 die annually .
Although considerable progress has been made in treating SAM [2–4], one way to reduce the burden of acute malnutrition is to prevent its emergence among children by increasing the resilience of poor and vulnerable households.
Poverty is generally acknowledged to be the major antecedent of malnutrition [5–7], and social protection and safety-net interventions are important to protect maternal and child nutrition . Recently, cash transfer programs (CTPs), which deliver direct unconditional or conditional cash to households, are being tested in developing countries . Such programs have been used in developed countries for many years as the main method for poverty reduction and social security. Although literature reviews of CTPs used in humanitarian relief interventions have appeared over the last few years, none has provided conclusive evidence of a sustained positive impact on child nutritional status, and several comment that the ways in which these interventions have an impact are not clearly understood [10–17]. Even if an increasing number of studies have highlighted a positive effect of CTPs in increasing diet diversity [18–20], food consumption [20, 21], health status [18, 22] and access to health care [19, 21], the evidence of a resulting effect on child nutrition is mixed and inconclusive, particularly in sub-Saharan Africa [18, 19, 23]. Nevertheless, evidence is emerging to show that complementary cash interventions could improve the results of nutrition interventions. In Niger and Somalia, cash transfers provided to households with acutely malnourished children improved recovery beyond the provision of ready-to-use therapeutic foods (RUTF) [24, 25]. CTPs appear to reduce the sharing of therapeutic foods and may improve the effectiveness of such interventions. It is also possible that the additional cash could increase the cost-effectiveness of the nutrition intervention, if gains in effectiveness more than balance the added cost of the subvention.
There is a particular need to determine the effect of CTP strategies and their impact on vulnerable households with malnourished members among different target groups and contexts. Most underlying causes of malnutrition are a function of people’s resources and social context. What households produce as well as the time they have to care for dependent members are determined by a range of social, economic and political factors; these are thought to include the division of labour, gender inequality, educational opportunities and property and power relations. When households have more money, they can diversify their diets by buying or growing food of a higher quality, being able to afford to attend the health centre and investing capital to create ongoing income-generating opportunities. Here, we hypothesised that additional cash will have a direct effect to improve the final outcome of children enrolled in a community-based management of acute malnutrition (CMAM) program. Specifically, within the household the cash would decrease intra-household sharing of the RUTF and improve the food diversity and consumption. The cash would improve the outcome of the malnourished child by reducing death, morbidity, transfer to hospital, defaulting, relapse or other causes of failure. The child would have higher rates of mid-upper arm circumference (MUAC) and weight gain and derived anthropometric indices.
This paper presents the findings from a clusterrandomised trial comparing the outcome of a standard Outpatient Therapeutic Program (OTP) for SAM and infant and young child feeding (IYCF) counselling with and without a monthly cash transfer over a 6-month period in the Democratic Republic of the Congo (DRC).