The MAM’Out project: a randomized controlled trial to assess multiannual and seasonal cash transfers for the prevention of acute malnutrition in children under 36 months in Burkina Faso

With at least 52 million wasted children in the world [1], wasting is a crucial public health issue. Although treatments for severely acute malnourished children exist and have proven their efficacy [2, 3], curative approaches remain very expensive [4] and more evidence is needed concerning strategies related to the management of moderate acute malnutrition [5]. The second Lancet Series on Maternal and Child Under-nutrition [5] and the Scaling-Up Nutrition Initiative [6] give some recommendations on selected effective approaches for the management and prevention of under-nutrition, such as breastfeeding counselling or micronutrient supplementation, but evidence gaps still remain, particularly concerning indirect interventions. The World Health Organization highlighted in 2010 the need to consider prevention strategies when implementing programs aiming at reducing acute malnutrition rates [7]. There is also evidence showing that preventive programs, such as supplementation, can be more effective to reduce childhood under-nutrition than nutrition rehabilitation [8]. Most scientific evaluations of nutrition rehabilitation are based on product distribution [9‐13]. However, products are not always locally available nor affordable for the target population. Considering the paucity of data pertaining to alternative context-adapted strategies for the prevention of acute malnutrition, research studies must be developed in order to produce evidence on effective, reproducible and cost-effective approaches [14].

Cash transfers, as part of a safety net approach, are relatively new in fragile states. Only a few safety net experiences for very poor and hunger vulnerable households have been implemented to date [15]. Indeed, humanitarian agencies have longstanding experiences with one-shot cash transfer interventions in emergency situations, but multiannual cash transfer is usually not implemented in countries exposed to acute malnutrition. Reviews on cash transfer experiences show that this type of intervention has the potential to prevent undernutrition [16, 17]. However, most of the cash transfer programs implemented and scientifically evaluated do not have a clear nutritional objective, which leads to inconclusive evidence regarding their nutritional benefits [18]. Hence, the MAM’Out (Moderate Acute Malnutrition Out) research project aims at assessing a context-adapted preventive approach, which is likely to influence several underlying causes of under-nutrition and not primarily based on food supplementation: seasonal and multiannual cash transfers. Indeed, as shown in Fig. 1, cash transfers can have an effect on all underlying causes of undernutrition. They have proven to be effective in removing financial barriers to health centers and nutritious food [19‐21], especially in Latin America countries. Positive effects of cash transfer programs on poverty reduction and food security [22], diet quality [23] and child health [19, 20] have also been documented. Some reports also suggest benefices on maternal mental health [24]. One can also hypothesize that benefiting from cash transfers can allow mothers to reduce their income generating activities, leading to more time for child’s care. Most of the cited evidence comes from conditional cash transfers. However, the conditional aspect of cash transfer can be associated with several disadvantages or constraints [25] and was sometimes shown not to be appropriated, especially in African countries [26]. The MAM’Out project will thus evaluate the effects of unconditional cash transfers on the prevention of undernutrition.

Furthermore, there is a lack of evidence related to the pathways by which cash transfers can improve child nutrition outcomes. In their review’s conclusion, Gentilini and Omamo [27] highlight the need for more targeted study designs that could attribute effects to specific processes. From an intended impact pathways model, Adato and al [19] already evaluated qualitative field studies in middle income countries to explain why expected nutrition and health outcomes do or do not occur: poverty, sociocultural norms and beliefs on health care practices seem to compete with cash. This research will follow the proposition made by some authors [21, 28] to use a program theory framework to analyze the way in which different components interact in order to have an effect.