Tender Description

1. Background and Justification
   Current evidence base on cash and voucher assistance (CVA) for nutrition. Despite the scale-up of CVA in emergencies,
   robust evidence on its effects on maternal and child nutrition remains limited and sometimes contradictory. The Global
   Nutrition Cluster has developed some guidance on the topic based on the evidence that exists and growing consensus
   on promising practice, including the Evidence and Guidance Note on the Use of Cash and Voucher Assistance for
   Nutrition Outcomes in Emergencies (2020) and CVA for Nutrition: challenges and promising practices. The limited
   research on CVA that does exist largely focuses on food-security impacts. Where CVA research does include nutrition
   outcomes, the focus is more on nutritional status and IYCF indicators. Almost no studies have looked at the use of cash
   to improve access and adherence to nutrition services for children who are already acutely malnourished. Finally, the
   effects (positive and negative) of targeting CVA to households with children who are or were recently suffering from
   acute malnutrition has rarely been studied, despite an increasing number of practitioners clearly piloting/
   experimenting with this approach (including many implementing agencies in Somalia).
   Evidence generation is particularly thin in Somalia’s humanitarian context. The Research on Food Assistance for
   Nutrition Impact (REFANI) and Cash for Improved Nutrition in Somalia (CINS) studies conducted in Somalia (by Concern
   and University College London) examined the linkages between cash transfers and nutrition outcomes. Both studies
   demonstrated a positive impact of cash assistance on household dietary diversity. The REFANI study found no
   significant difference in the incidence and prevalence of global acute malnutrition (GAM) between intervention groups.
   However, households receiving cash transfers showed increased total household expenditure, improved dietary
   diversity, and higher food consumption scores. Women specifically experienced improved dietary diversity and a small
   but statistically significant increase in maternal MUAC. The CINS study, informed by the findings of the REFANI, further
   revealed that carefully designed conditionalities can significantly improve the uptake of essential health services,
   namely timely vaccination for children under five years of age. While SBC interventions (health audio messages) were
   found to enhance household dietary diversity, they did not result in measurable reductions in child morbidity,
   malnutrition, or mortality. These findings highlight that while cash transfers can strengthen household-level food
   security and access to services, their direct impact on child nutrition outcomes may be limited without complementary
   interventions1
   Preliminary results from recent study conducted in Somalia by Save the Children and John Hopkins University found
   that a Cashplus for Nutrition programme providing a cash transfer and intensive social and behaviour change in the
   form of mother-to-mother support groups reduced wasting prevalence and incidence in the Bay and Hiraan Regions
   versus cash alone given in two different amounts (90/70 USD vs. 125/105 USD in the two locations, respectively). See
   the Resourcing Families for Better Nutrition in Somalia - Evidence Brief (2025, paper soon to be published).
   Since 2022, the Somali Cash Consortium (SCC) has been delivering lifesaving multipurpose cash assistance (MPCA) to
   families of children with SAM with complications admitted to Stabilisation Centres (SCs). The cash amounts disbursed
   on rolling basis to beneficiaries are fully aligned with the Minimum Expenditure Basket (MEB) and the Transfer Value
   (TV) endorsed by Somalia Cash Working Group. Transfer amounts vary slightly between districts to reflect local price
   differences. Through a partnership with the Caafimaad+ Consortium - specialised in nutrition and health-care services

• more than 3,000 households have received targeted support. Preliminary monitoring suggests notable reductions in
  default and relapse, as well as improvements in caregiver wellbeing; however, robust, prospective evidence is still
  lacking. Since 2024 the SCC has been routinely collecting baseline data on this cash-for-nutrition modality, generating
  1 Evidence and Guidance Note on the Use of Cash and Voucher Assistance for Nutrition Outcomes in Emergencies |
  Global Nutrition Cluster
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  a robust dataset ready for secondary analysis and review. In parallel, Caafimaad+ partners have assembled extensive
  nutrition-programme data from 22 districts across Somalia. Both datasets will be made available to the consultant or
  research firm to inform and enrich the planned analysis.
  While the cash assistance provided as part of the intervention is not designed to directly contribute to the clinical
  recovery of children with SAM, this research seeks to unpack the indirect yet critical role that cash support plays in
  improving treatment outcomes for children with SAM. By addressing economic barriers across different stages of care,
  from admission to discharge and follow-up, cash transfers have the potential to strengthen program performance and
  reduce the risk of relapse. These insights are particularly relevant for humanitarian and fragile contexts where food
  insecurity, poverty, and limited access to health services intersect to undermine the impact of standard nutrition
  interventions.
  In line with DG ECHO’s 2025 Health Policy Guidelines this study aims to identify innovative, evidence-driven approaches
  that reduce excess morbidity while upholding humanitarian principles. Specifically, the study responds to the gaps in
  evidence regarding if and how targeted cash transfers can improve adherence to SAM treatment services and improve
  recovery, relapse and overall cost-effectiveness. Findings will inform DG ECHO partners and global clusters on
  optimising CVA design for nutrition impact.
  Common challenges children with SAM and their caregivers face when seeking treatment. Below are a number of
  barriers identified via observation and key informant interviews with programme participants in Somalia.

1. Caregiver willingness to remain at the stabilization centre (SC): A common challenge in treating children admitted
   to SC is that caregivers, usually mothers, often do notstay at the Stabilization Centre (SC) for the full treatment period.
   This is mainly because many of them are the main earners in the family or have other children and responsibilities at
   home. Staying at the SC means they lose income and cannot take care of other needs, which makes it hard to remain
   until the child fully recovers. As a result, some leave early or drop out of treatment altogether. Providing cash
   assistance can ease some of this financial stress, helping caregivers stay longer and focus on their child’s recovery
   without worrying as much about lost income or unmet household needs.
2. Hidden costs of SAM treatment: Although treatment for SAM with complications is generally provided free of
   charge, families frequently incur additional, unanticipated expenses. These may include costs related to
   transportation, food, diagnostics, or medications for comorbidities not covered by the facility. In many cases,
   caregivers are either asked or expected to bear these costs. These out-of-pocket expenses can be a barrier to
   completing treatment. The cash assistance might allow families to cover these unexpected costs, ensuring that the
   child received full and timely care.
3. Household resources overstretched leading to poor recovery after SC discharge and risk of relapse: Once the
   child is stabilised in the SC, they are referred to OTP to continue treatment. However, OTP services may not be
   available or hard to access in many areas. Even when available, food insecurity at home often leads to sharing of the
   therapeutic food (RUTF), which reduces its effectiveness. Cash assistance might help families meet basic needs,
   reducing the pressure to share RUTF and increasing the likelihood of treatment adherence and sustained recovery.
   Why CVA for nutrition? Cash assistance intrinsically promotes dignity and autonomy. 2Allowing households to decide
   how to allocate resources empowers them to prioritise their most pressing needs - whether medical fees, transport,
   nutritious foods, or other essentials - rather than being limited to in-kind rations or other items. By giving recipients,
   the flexibility to address multiple drivers of malnutrition, MPCA strengthens resilience and respects recipient
   households’ agency, principles that are at the core of humanitarian action. Support to ensure health and nutrition
   treatment service are available and households make informed choices to promote their child’s recovery are also
   essential alongside cash.
   2 Multipurpose Cash Assistance - The CALP Network; Protection Sector Cash Guidance May 2022_TO SHARE.pdf;
   asiapacific.unfpa.org/sites/default/files/pub-pdf/2024-11/CVA.BGD24.v.2.2.pdf
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   Findings of the research will be use to adjust cash programme design and will be disseminated amongst Cash Woking
   Group and Nutrition Cluster members in Somalia.
4. General Objective
   Generate high-quality evidence regarding if/ how integrating cash transfers into the package of support for SAM
   children with complications admitted to stabilization centers (SC) influences programme adherence, recovery, relapse
   within six months of discharge, and cost-effectiveness.
5. Specific Objectives
   Adherence to stabilisation centre care: Measure the effect of providing MPCA to support transport and caregiver meal
   support received on default rates during stabilisation centre (SC) care. Document different approaches3
   to providing
   transport and meal support existing at SC and the relative efficiency of each from the provider and recipient
   perspective.
   Medical expenditure: Determine the extent to which MPCA improves households’ financial capacity and affects
   household expenditure on medicines, consultations and other treatment-related costs. Describe the ‘hidden’ medical
   costs and other out of pocket expenses associated with an SC stay.
   Recovery: Assess whether a 3-month household MPCA allocation provided at admission to the SC can improve overall
   recovery from the outpatient therapeutic programme (OTP) and shorten length of stay.
   Relapse Prevention: Track relapse to SAM with complications within three months post-discharge among children
   whose caregivers receive three-month post-treatment cash versus none.
   Cost effectiveness. Calculate the incremental cost-effectiveness ratio (ICER) for each intervention arm, expressed as
   the cost per additional child recovered and the cost per relapse prevented.
   Investigate how the cash assistance influences women’s decision-making autonomy, cash expenditure patterns and
   the distribution of their time between caregiving, household tasks, and income-generating activities.
6. Scope of the Study
   Geography: Somalia – Banadir and Gedo districts.
   Population: Households with children with SAM with medical complications admitted to SC and who go on to continue
   treatment in OTP programme.
   Duration: 6 months (design, data collection, analysis, dissemination).
   Partners: Caafimaad +, SCC Implementing Partners, Somali Ministries of Health, the Global CVA for Nutrition Working
   Group (under the Global Nutrition Cluster), and local research institutions. Technical support will be provided by
   Concern/ SCC technical advisers at country and HQ level.
   Responsibilities: SCC partners will support the on boarding process, facilitate the consultant’s work, and provide
   logistical support as needed to help achieve the objectives of the assignment. SCC will make available relevant data
   from existing cash and nutrition interventions. However, the consultant will be fully responsible for data collection,
   analysis, and the production of all deliverables.
7. General Methodology
   The selected consultant shall develop and submit a stand-alone Methodology Proposal that translates the study’s
   objectives and scope into a coherent research approach. The proposal must describe, in clear and concise terms, the
   study design, sampling framework, data-collection methods (quantitative and qualitative), data-analysis plan, ethical
   3 Different approaches refer to receive support through MPCA, through direct support provided by the Stabilization Center.
   In Somalia co-exists different approaches depending on resource availability as not all the Stabilization Centres offered
   the same support.
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   safeguards, quality-assurance procedures, and risk-mitigation strategies. Each methodological choice should be
   justified with reference to established best practice in cash-transfer and nutrition-impact evaluations and tailored to
   the operational realities of Banadir and Gedo.
   Once the Methodology Proposal is approved by the SCC & Caafimaad+ project’s steering committee and relevant ethics
   bodies, the consultant will transform the plan into concrete implementation materials: data-collection tools, training
   curricula, standard operating procedures, and a high-level statistical analysis plan. The consultant will oversee pilot
   testing, ensure robust data management and protection, and produce interim progress updates, culminating in a
   cleaned and documented dataset, final analytical report, and manuscript suitable for submission to a peer-reviewed
   journal.
   Extensive secondary data are already at hand to underpin this study. SCC and its partners have compiled cleaned, welldocumented datasets from all cash-for-nutrition interventions implemented in 2024 and 2025—including household
   baseline/end-line surveys, transfer records, post-distribution monitoring, and routine programme dashboards. In
   addition, several SCC-commissioned research studies on Cash-Plus/SAM pathways completed during the same period
   are available for meta-analysis. For the nutrition component, beneficiary-level clinical data—covering admission,
   treatment progress, and discharge outcomes in Stabilisation Centres (SC) and linked Outpatient Therapeutic
   Programmes (OTP)—are routinely captured and can be shared by SCC implementing partners through established datasharing agreements. Together, these resources provide a rich empirical foundation that will accelerate study start-up,
   enhance statistical power, and enable robust triangulation of new findings.
8. Expected deliverables
   During the period of this assignment, the consultant should provide the below deliverables:
   Deliverable 1: Inception report – refined appropriate study methodology including the analysis framework, study
   objectives, data collection tools, sampling techniques, and realistic work plan as well as confirming the consultant’s
   understanding of the ToR
   Deliverable 2: One Policy Learning brief/paper clearly providing deepen understanding of the findings of the study,
   summarizing the core facts and statistics related to the subject. Consultant should highlight the main takeaways and
   implications of the subject and suggest policy measures to improve cash interventions.
   Deliverable 3: Prepare a presentation with findings and recommendations from the research that will be presented to
   CWG, health/nutrition cluster and through other channels for information and knowledge sharing
   Deliverable 4: Produce the final report accommodating the inputs and feedback provided including infographics for
   the study that can be easily used for advocacy purposes
9. Period of the consultancy
   This consultancy assignment will take a maximum of 70 working days, including travel and weekends.
   The consultant will provide a detail calendar explaining what the key steps for the consultancy are:
   Description Days Estimated date
   Deliverable 1: Inception report
   Field work: Information gathering/consultation and data
   analysis
   Preliminary draft of the Consultancy report including main
   findings & key recommendations.
   Preliminary draft of the Policy Learning Brief (PB)
   Review & comments from SCC partners & Consultants
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10. Consultant/firm’s Profile
    The consultant should be an expert with the following competencies:
    • Master’s degree (or higher) in Public Health, Nutrition, Health Economics, Epidemiology, or related social
    science.
    • At least 5 years of demonstrated experience in health-nutrition related studies.
    • Strong experience in conducting research and assessments
    • Experienced in working in Somalia and knowledge of the Somali context
    • Can undertake part of the information gathering in-country
    • Capability to meet tight deadlines and adapt to volatile field conditions
    • Excellent communication and coordination skills
    • Fluency in written and spoken English and Somali
    • Demonstrated experience and skills in facilitating stakeholder/working group consultations
    • Experience in working with Government and NGOs/INGOs/Donors
    • Knowledge of ECHO 2025 Health Policy Guidelines, Global Nutrition Cluster CVA guidance, Sphere standards,
    and CaLP -health nutrition guidelines is an asset.
11. Application procedures
    The consultant that fits the requirements should submit an expression of interest in English that is a maximum of 15
    pages long and should include the following:
    • A technical proposal with a detailed response to the TOR, with a specific focus on the specific objectives,
    deliverables, and key selection criteria for respondents.
    • A financial proposal detailing the itemized breakdown of the consultancy work, i.e. the number of
    units/days/weeks and rates, and other modes of payment.
    • Methodology and Implementation Plan.
    • Company profile and CVs of the core experts that sufficiently demonstrate his/her background in Policy and
    Advocacy research.
    • A list of 5 recent publications of pertinent articles and research papers published in reputable and highly cited
    journals.
    • Initial work plan based on realistic timelines.
    • Samples of similar work undertaken by the company or the lead consultant.

Skills Required

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