Evidence and Guidance Note on the Use of Cash and Voucher Assistance for Nutrition Outcomes in Emergencies

Evidence Note
There is a growing recognition that Cash and Voucher Assistance (CVA) can contribute to improving 
maternal and child nutrition by impacting on the underlying determinants of adequate nutrition. This can
occur in three main ways.  
i. CVA allows targeted households and individuals to purchase goods and access services that can
have a positive impact on maternal and child nutrition. These include nutritious foods, items to
prepare food, hygiene items, safe water, health services and medication, transportation, and
productive inputs.  
ii. If provided conditionally, CVA can improve participation in nutrition Social Behaviour Change (SBC)
activities and attendance to priority preventive health services.  
iii. Further, the increase in household income associated with CVA can reduce economic pressures
and household tensions, in turn increasing the time available for caregiving, enhancing women’s
decision-making power, and improving psychological well-being of caregivers. 
CVA can be effective in addressing economic barriers to adequate nutrition. These include financial
barriers related to the lack of purchasing power at the household level to access goods and services,
as well as opportunity costs of care giving behaviours. The potential of CVA to address economic
barriers depends on a functioning supply side (e.g. the availability of nutritious foods in the market). The
precise pathways of how CVA impacts nutrition are to a large extent determined by the spending
decisions of households and individuals, which are again determined by social and cultural norms,
programmatic decisions in relation to design and targeting and other contextual factors. 
There is a sizable and growing body of evidence about CVA and nutrition outcomes, derived mainly
from development settings but increasingly also from humanitarian settings. The evidence base for the
impact of CVA on acute and chronic malnutrition is mixed. At the level of immediate determinants of
nutrition, the evidence for the impact of CVA on the dietary diversity of children is mostly positive, while
the evidence for impact on the health status of children is limited. At the level of underlying determinants,
the evidence for the impact of CVA on household food security indicators and the uptake of preventative
health services is relatively strong and mostly positive. There is no evidence for an impact of CVA on
care behaviours.  
Based on the existing evidence, there is a broad consensus within the nutrition sector that CVA alone
is in most circumstances not sufficient to impact nutrition outcomes. CVA is most effective when
complemented with other nutrition-specific and nutrition-sensitive interventions. Based on this
consensus, many humanitarian organizations have developed cash plus or complementary
programming approaches that call for household cash transfers to be complemented by additional
measures to holistically address the most important demand and supply-side barriers. 
Based on a review of peer-reviewed studies and operational examples, this Evidence Note identifies
five main approaches to integrate CVA in nutrition response to prevent or treat malnutrition. These
approaches can sometimes form the basis of a response on their own, can be combined with each
other, or can be part of a wider integrated response. They include: 
1) Use CVA for household assistance and/or individual feeding assistance: CVA modalities can be
considered for both components with important limitations on individual feeding assistance.
Combining household cash transfers with specialised nutritious foods is a promising approach to
prevent malnutrition that warrants further exploration. Also, various humanitarian organizations
have had positive operational experiences with the provision of fresh food vouchers to diversify
diets.  
2) Combine household CVA with SBC interventions: There is relatively strong evidence that combining
household cash transfers with SBC can be an effective strategy to prevent child malnutrition. The
two components seem to mutually reinforce each other in the sense that SBC activities seem to 
promote child/women-centred spending decisions, while the cash transfers allow caregivers to put
some of their acquired knowledge and skills into practice. Therefore, CVA modalities that aim to
contribute to nutrition outcomes need to be accompanied with context-specific SBC interventions. 
3) Provide conditional cash transfers as an incentive to attend to priority health services: There is
relatively strong evidence (mainly from development settings) that cash transfers conditional on the
attendance of free priority preventative health services can improve the uptake of these services.  
4) Cash or vouchers to facilitate access to treatment of malnutrition: CVA can be effective in
addressing indirect costs to accessing treatment of malnutrition related to transportation as well as
food and accommodation if the child requires in-patient care and the caregiver needs to stay at the
treatment centre. 
5) Provide household cash or vouchers as part of treatment of severe acute malnutrition (SAM): The
provision of household CVA to caregivers who bring their child for the treatment of SAM has
demonstrated potential to improve recovery and reducing defaulting and non-response to
treatment. At the same time, there is anecdotal evidence that some caregivers may keep or make
their child malnourished in order to access assistance.

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