Implementing Locally Sourced Food Vouchers and Unrestricted Cash Transfers for Moderate Acute Malnutrition Management in Ethiopia: Implementation Lessons from the VIMAM Trial

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.