Presentation (CTI)

OBJECTIVES: Severe acute malnutrition (SAM) remains a major contributor to child morbidity and health system strain in Northwest Nigeria despite sustained humanitarian investment. In fragile contexts characterized by economic collapse, incentive-based interventions are increasingly used to improve nutrition outcomes. In 2023, a conditional cash incentive was introduced for caregivers of children discharged from Inpatient and Ambulatory Therapeutic Feeding Centres (ITFCs/ATFCs) to reduce relapse and strengthen post-discharge food security. However, attaching monetary value to treatment outcomes raised concerns about unintended behavioral responses. To assess the impact of incentive-based nutrition programming on child health outcomes, caregiver behavior, and program integrity in Northwest Nigeria.
METHODS: A mixed-methods explanatory study was conducted using routine program data (CognosTech) and qualitative interviews. Quantitative analysis included all eligible children aged 6-59 months discharged from ITFCs/ATFCs between January and September 2024 across Katsina (Marusa), Sokoto (Kware), and Kebbi (Jega) States (census sampling; n=1,103). Multivariate logistic regression assessed associations between incentive exposure and outcomes. Purposive qualitative interviews with caregivers and frontline providers explored behavioral adaptations and safeguarding risks.
RESULTS: Among 1,103 discharges, 28.6% experienced SAM relapse within 90 days and 22.1% had repeat admissions. Incentive exposure was independently associated with higher odds of repeat admission (adjusted odds ratio = 1.54; 95% CI: 1.19-1.99). Qualitative findings identified high-risk coping behaviors in contexts of extreme deprivation, including child substitution during admissions, temporary caregiving arrangements involving already malnourished children, and deliberate actions to meet clinical admission thresholds for ITFC/ATFC. These behaviors were linked to the monetization of treatment outcomes and the informal economic value of therapeutic commodities.
CONCLUSIONS: From a health economics perspective, poorly calibrated incentives can distort caregiver behavior, reduce program efficiency, and generate avoidable health system costs. Nutrition programs in fragile settings must integrate ethically grounded incentive design, safeguarding mechanisms, and community-informed accountability to ensure child-protective, value-based outcomes.