Reviewer s report. Version: 0 Date: 19 Dec Reviewer: Saskia de Pee. Reviewer's report:

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1 Reviewer s report Title: Effects of Unconditional Cash Transfers on the outcome of treatment for Severe Acute Malnutrition (SAM): a Cluster Randomized Trial in the Democratic Republic of Congo Version: 0 Date: 19 Dec 2016 Reviewer: Saskia de Pee Reviewer's report: This manuscript by Grellety and co-authors is an interesting and well written paper. The marked difference of incidence of acute malnutrition post SAM treatment in the two groups is a very important finding to report. However, some of the findings and their implications need to be better described and discussed, as per my comments below. Main comments 1. It is important to state clearly that the cash was provided to augment the standard treatment with RUTF of children with SAM, during and after the treatment, for a total of 6 months. This should for example be made clear in the title and the background paragraph of the abstract. 2. The findings indicate that the cash provided access to a more diverse diet that appears to have made a substantial contribution to reducing the risk of acute malnutrition reoccurring. At the same time it was noted that linear growth remained unchanged among the intervention and comparison groups. a. Provide more information on dietary diversity assessments, in particular the number of food groups that were included for the HDDS and IDDS (lines ); the reporting of improvements of the scores should be in absolute terms, i.e. score improved from x to x in cash and y to y in comparison group instead of by comparing the magnitude of increments (lines ); provide more information on the types of foods that were consumed more of (lines 414-8). b. Provide some information on foods that were available in the market, to support your point (lines 580-2) of impact being context specific, i.e. impact of cash on nutritional status depends, amongst others, on the nutrient-content and -density of the foods that can be purchased.

2 c. Discuss which components of dietary intake may have improved most - e.g. energy and protein, thus more food available to everyone?; dietary diversity enabling higher intake of a range of (micro)nutrients with an impact on morbidity? And discuss that further improvements of food intake would be required in order to increase the chances of also impacting linear growth and what types of foods this may require (e.g. animal source foods, fortified foods?). d. One hypothesis would be that micronutrient-rich foods reduced the risk of morbidity and that that reduced the incidence of acute malnutrition. A very cost-effective way to increase MN intake is through fortified commodities, including micronutrient powder, which may be available in the market or provided through specific programming that target by age or could be provided post acute malnutrition treatment. Good if you can discuss the pathways through which the cash may have reduced incidence of SAM and through what other ways that impact could potentially be achieved, whether among vulnerable children in general or those that were treated for acute malnutrition (see also point 3 below). 3. Cash is a means to increase purchasing power and improve livelihoods. Social safety net programming typically targets the poorest households. In their conclusions, the authors suggest that cash is provided, for a limited period of time, to households that had a child treated for SAM, in order to prevent SAM from reoccurring. This is a very different approach in which households become eligible for cash support based on illness in a specific individual with the aim of preventing that from happening again. Besides a perverse incentive that this could create, it also means that prevention is targeted at individuals amongst whom prevention has already failed, instead of at subgroups with a higher risk. Prevention of undernutrition (wasting, stunting, micronutrient deficiencies) should target households with pregnant women, breastfeeding women and young children (i.e. first 1000 days) with risk factors such as severe poverty or high risk of food insecurity, and provide them with access to a more nutritious diet, in particular for the most nutritionally vulnerable individuals. This can be in the form of cash and/or specific nutritious foods, where a combination may be the most effective for prevention among specific individuals as it may achieve a higher intake of required nutrients (e.g. Langendorf study found twice lower risk of MAM incidence among the group with a slightly lower amount of cash combined with a special nutritious food as compared to the cash only, or special food only, groups). Furthermore, SBCC on good IYCF practices, including hygiene and safe food preparation and storage is required for any of these approaches. Which approach is most appropriate and feasible in a specific context depends on many factors, such as costs, feasibility of sourcing and distributing certain commodities, platforms to identify eligible households or individuals, prevailing practices and perceptions around IYCF, capacity of health, food and community systems etc.

3 The authors should distinguish between their findings of impact of increased purchasing power, achieved through the provision of cash, on risk of acute malnutrition, implemented among very vulnerable children, i.e. those that were treated for SAM, and the implications of these findings for strategizing on how to prevent undernutrition and amongst whom. 4. Lines it's very important to mention that in an emergency situation, households often receive food assistance in the form of a general food distribution (GFD), which covers the households basic food needs and is similar to the role of the cash in this study. 5. How clear was the link for the caretakers between having a child who received treatment for SAM and receiving cash support for 6 months? Good if this can be described more clearly in the paper. Minor points: 1. Line 195, add the reference for the WHO criteria. 2. Line 315, as lower hazard ratio's are better, replace 'less' with 'lower'. 3. Lines 373-5, when a child has SAM, that indicates higher vulnerability of the household, but not everyone is severely malnourished. Edit the sentence. 4. Lines , at what point were the IDDS data collected, during or after SAM treatment? 5. Lines 465-7, do you mean 'food security' or 'food and nutrition security' instead of 'food and social security'? If the higher food security was enabled by social safety net assistance, please add this point. 6. Line , add availability of diverse types of food as another requirement. 7. Lines 590-2, if food insecurity was relatively low, is the high prevalence of wasting more due to high morbidity, and if so, what other measures for prevention would be recommended in addition to improving household purchasing power? Or, is wasting high among poor households where food insecurity is very high, even when the area is characterized as having low food insecurity?

4 8. Table 7. The table needs editing. It appears to report incidence and HR for malnutrition but the column heading and footnote states 'recovery', which suggests that there were fewer recovery events and lower odds of recovery in the intervention arm. 9. Supplementary table 2. Edit title for clarity, i.e. discharge means that the children recovered, so what does 'recovered after discharge' refer to when recovery is a condition for discharge? Are the methods appropriate and well described? If not, please specify what is required in your comments to the authors. Yes Does the work include the necessary controls? If not, please specify which controls are required in your comments to the authors. Yes Are the conclusions drawn adequately supported by the data shown? If not, please explain in your comments to the authors. No Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review? If an additional statistical review is recommended, please specify what aspects require further assessment in your comments to the editors. I am able to assess the statistics Quality of written English Please indicate the quality of language in the manuscript: Acceptable Declaration of competing interests Please complete a declaration of competing interests, considering the following questions: 1. Have you in the past five years received reimbursements, fees, funding, or salary from an organisation that may in any way gain or lose financially from the publication of this manuscript, either now or in the future? 2. Do you hold any stocks or shares in an organisation that may in any way gain or lose financially from the publication of this manuscript, either now or in the future? 3. Do you hold or are you currently applying for any patents relating to the content of the manuscript?

5 4. Have you received reimbursements, fees, funding, or salary from an organization that holds or has applied for patents relating to the content of the manuscript? 5. Do you have any other financial competing interests? 6. Do you have any non-financial competing interests in relation to this paper? If you can answer no to all of the above, write 'I declare that I have no competing interests' below. If your reply is yes to any, please give details below. I declare that I have no competing interests I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license ( I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published. I agree to the open peer review policy of the journal