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

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.