Conditional cash transfer and stunting prevention: Evidence from Bima, West Nusa Tenggara

Abstract

Stunting has become a global problem that contributes to many deaths in children and is an indicator of inequality in human development. This study seeks to explain the pathways by which the Indonesian conditional cash transfer (CCT), namely, the Family Hope Program (FHP), can help reduce the stunting rates in Bima City, West Nusa Tenggara, Indonesia. In Bima City, the stunting rate decreased by more than half within the last five years from 36.5% in 2017 to 14.81% in 2022. Using thematic analysis, this study identifies the possible mechanisms of how the FHP can influence child nutrition based on semi-structured in-depth interviews with 15 beneficiary households of FHP throughout five subdistricts in Bima City. This study finds that some pathways of FHP contribute to reducing stunting in Bima City, such as through cash transfers to women, micronutrient intervention, education in health and nutrition from program facilitators, and health visits as a program conditionality. The external environment also matters in supporting the stunting reduction in Bima City, for example, the existence of applications to report stunting, field visits from health workers, and the role of higher education institutions.

Keywords:

• conditional cash transfer
• stunting
• child nutrition
• health

1. Introduction

Stunting disrupts children’s growth and development process caused by a lack of nutritional intake and recurrent infections. The main periods of life of the first day, starting from the first thousand days, from the fetus to the age of two years, are essential in a child’s growth. Referring to child growth standards according to the World Health Organization (WHO), a child is categorized as stunted based on anthropometric index measures, by measuring body length in children under the age of two years and measuring height in children over two years old with a z-score of less than − 2 standard deviation.

Stunting has become a global problem that contributes to many deaths in children and is an indicator of inequality in human development. In 2020, as many as 149.2 million children under the age of five were stunted globally, especially in poor and developing countries (Nabwera et al., 2021). The stunting rate in Southeast Asia is among the highest in the world, even with a declining trend.¹ As a country with the largest population in Asia, the prevalence of stunting in Indonesia has decreased by 1.6% per year from 27.7% in 2019 to 24.4% in 2021.² The high prevalence rate of stunting can permanently limit a child’s physical and cognitive well-being, thus affecting the quality of life of a child until adulthood (Amin et al., 2022; Batool et al., 2023; de Onis & Branca, 2016). Unlike the case with children who grow optimally, they tend to have a better level of intelligence, which will later be less competitive in the labor market (Woldehanna, 2017).

Several previous studies have discussed the issue of stunting in Indonesia, where the focus of the research is related to risk factors and the impact of stunting prevention programs. One of them is a study conducted in Papua by Wulandari et al. (2022), which found that mothers with low levels of education increase the risk of stunting in children due to low awareness of children’s health. Meanwhile, a mother with a higher education level usually has better nutrition awareness and knowledge (Batool et al., 2023). It is supported by Wahyuningsih et al. (2022), who mentioned that low public awareness of nutrition is a factor that causes high stunting rates. Low awareness is caused by the mother’s lack of knowledge about nutrition, which impacts the suboptimal fulfilment of toddler nutrition, hence children experience delays in growth and development (Amin et al., 2022).

In line with this research, another study discusses stunting prevention in Lombok, West Nusa Tenggara (Darawati et al., 2020). The stunting prevention program provides counselling and nutrition education to mothers and toddlers with local community leaders, which is carried out regularly once a week for six weeks. The program has been shown to influence the intake of nutrients in the form of energy, protein, carbohydrates, vitamin C, iron, calcium, and fibre received by children. Another piece of evidence is found in differences in maternal knowledge scores regarding balanced nutrition before and after counselling and educational activities.

Another study by Hafid et al. (2021) revealed that stunting prevention efforts in children with the most prominent effect are breastfeeding children up to two years of age. It is corroborated by the results of Darwis et al. (2021), who found that one of the factors causing the high stunting rate is the suboptimal provision of breast milk to children up to two years of age. Suboptimal breastfeeding is caused by a decrease in breast milk experienced by most mothers when the child is still 4–12 months old. The decrease in the amount is due to the lack of nutrients from the mother.

So far, there has been no research linking conditional cash transfer (CCT) programs as an intervention to stunting prevention in the qualitative realm. Previous research has focused on quantitative analysis, so the conclusions obtained were only limited to statistical influence. For example, a quantitative study by Cahyadi et al. (2020) found a significant impact on the likelihood of children being stunted during the six-year implementation period of the Family Hope Program (FHP). There was a 23% to 27% decrease in the probability of stunting. Both boys and girls benefit from FHP in reducing stunting, although boys benefit more than girls.

Theoretically, CCT programs can affect child nutrition through various pathways (Leroy et al., 2009). Cash assistance can increase recipient households’ income, allowing households to buy more nutrient-rich food, thereby improving household food security. As a critical target of CCT programs, women become more empowered in their decision-making regarding child nutrition and health. Programs accompanied by feeding and supplements rich in micronutrients can directly improve the child’s nutritional status throughout, leading to the child’s diet improvement. Without micronutrient intervention, cash transfers may not meaningfully improve access to food regularly, especially when the transfer value is low (Ndlovu et al., 2021).

In addition to income gains from the CCT program, Vazir et al. (2012) further showed that child nutrition development scores could be improved with educational program strategies, especially nutrition education. The findings have important implications for helping malnourished children from rural communities in India to start school at a developmental level appropriate to their age. The results of the food security understanding program in the form of increasing children’s intake of energy, protein, vitamin A, calcium, and iron have succeeded in reversing the decline in children’s growth rates during the 12-month program with home visits twice a month.

The nutrition and health education component of the CCT program, usually also aimed at women as program beneficiaries, can change their preferences for nutrient-rich foods, shifting household expenditures to food allocation. In addition, conditional cash transfer programs typically require mothers, children, and other family members to follow a regular schedule of primary health care visits. It can increase the use and access to health services worldwide. The benefits of health services also improve children’s nutritional status by regularly checking their health conditions. However, this requirement can also negatively affect women’s time, especially if women have to travel long distances to receive payment, adhere to scheduled health visits, and/or attend health counseling sessions.

Program requirements to enroll and maintain the attendance of school-age children in schools can also have a long-term intergenerational effect on nutrition through women’s education pathways and child nutritional status. Better nutrition in early childhood can improve cognitive development and educational attainment, leading to higher economic productivity in adulthood (Hoddinott et al., 2008; Ruel & Hoddinott, 2008), and therefore has the potential to have children with better nutrition in the next generation.

The limited literature linking the role of conditional cash transfer programs, especially FHP, with stunting rates provides room for a more nuanced exploration of this relationship through qualitative analysis. It is in this regard that this paper aims to contribute to the scholarly discourse by investigating the pathways through which the Family Hope Program (FHP) has influenced stunting rates in Bima City, West Nusa Tenggara, Indonesia. Qualitative analysis is particularly beneficial in this context as it enables a deeper understanding of the multifaceted and context-specific factors that contribute to stunting reduction. Quantitative data can provide a broad overview of trends, but qualitative data allows us to explore the “why” and “how” behind these trends. By engaging with the experiences and perspectives of FHP beneficiary households through in-depth interviews, we can gain insight into the complex interplay of factors, such as cultural norms, household decision-making dynamics, and local health service delivery, that shape the program’s impact. Additionally, qualitative analysis allows for a more comprehensive exploration of the role of external environmental factors in supporting stunting reduction efforts, providing a more holistic view of the mechanisms at play.

Bima City presents a unique and compelling case study for exploring the impact of CCT programs on stunting prevention for three key reasons. First, Bima City has achieved an exceptional reduction in stunting rates, decreasing by more than half within the last five years from 36.5% in 2017 to 14.81% in 2022.³ This remarkable progress in stunting reduction significantly outpaces national trends, highlighting the effectiveness of targeted interventions in this specific area. Second, Bima City is situated in the eastern part of Indonesia, a region that historically lags in terms of development. The latest data from Statistics Indonesia in 2022 mentioned that the economic growth of Bima City is the lowest in West Nusa Tenggara Province, notably at 2.7%. Despite these developmental challenges, the city has made significant strides in addressing stunting, offering valuable insights into the pathways for stunting prevention in regions with similar developmental contexts. Lastly, Bima City’s resilience in the aftermath of a devastating flash flood in 2016 underscores the importance of community engagement and multifaceted approaches in combating stunting (Rokx et al., 2018). The fact that the city has been able to make such impressive progress despite the setbacks caused by the natural disaster illustrates the potential of a comprehensive approach that includes cash transfers, micronutrient intervention, health and nutrition education, and mandatory health visits.

Therefore, situated within this context, the primary objective of this study is to investigate how the FHP can contribute to stunting reduction in Bima City. The rest of the paper continues with a description of the FHP and the context of Bima City, focusing on the city’s socio-economic attributes and recent stunting rate reduction. We then detail our methodology, including participant selection, data collection instruments, and analysis methods. In the results and discussions section, we explore the findings from interviews with FHP beneficiary households, examining factors contributing to the decrease in stunting rates and the role of external influences. The paper concludes with a summary of key insights, their implications, and recommendations for future stunting prevention initiatives.

2. Description of the Family Hope Program

This segment will provide a full description of the Family Hope Program’s design. It encompasses the program’s objectives, participant eligibility criteria, conditional requirements, and the household-specific benefits bestowed. Additionally, we will delve into the institutional context against which this study has been conducted.

2.1. The design

The Family Hope Program (FHP), which was first launched by the Indonesian Ministry of Social Affairs (MoSA) in 2007, seeks to enhance the quality of human resources through cash transfer provisions conditional upon households accessing basic health and education facilities. The program eases the financial burden of poor households while at the same time encouraging their investments in the children’s future through better health and improved education. The recipients of the program are those ranked below a certain poverty cut-off set by the Central Bureau of Statistics using economic and asset-based measures.⁴ The eligible households also must contain at least one of the following criteria: a pregnant or lactating woman, having an infant or toddler, children at a schooling age, an elderly aged 70 years or more and not covered by other social protection programs, and a severely disabled person. In particular, the FHP recipients must meet the conditionalities specified in Table 1.

Table 1. List of FHP conditionalities

No	FHP program criteria	Conditionalities
1	Households with pregnant or lactating mothers	Four prenatal visits to the health clinic throughout trimesters Patients giving birth with the aid of medical staff in the health clinic Two antenatal checks before the first month
2	Households with infant
	−0 to 11 months	Complete monthly immunizations and weight monitoring
	−6 to 11 months	Receive vitamin A supplements
3	Households with toddler
	−1–5 years	Monthly additional immunizations and weight monitoring
	−5–6 years	Monthly weight monitoring and receiving Vitamin A twice a year
	−6–7 years	Body mass index measurement at the health clinic
4	Households with children aged 6 to 21 years who have not completedmandatory education (primary and secondary school) mandatory education (primary and secondary school)	Registered at a school or equivalent program Minimum class attendance of 85%
5	Households with severe disabilities	Medical care as necessary Health workers can conduct medical check-ups via home visits (home care) and participation in social activities (daycare)
6	Households with elderly aged 70 and older	Check-ups can be conducted by health professionals or by visiting a health center or special clinic for the elderly. Taking part in social activities (daycare) and home care

Source: National Team for the Acceleration of Poverty Reduction.

Women are the recipients of FHP given their primary role as caretakers and caregivers of their children. The fund is distributed quarterly through automatic teller machines (ATMs) or the nearest post office. There are no certain requirements on how to spend the funds for the recipients, yet it is advised for them to use the cash transfer for their children’s related needs. Although cash transfers through electronic money may contribute to household spending for child-related needs since it can be tracked and recorded, this study does not explore this issue further given the scope and focus of this study. The benefits received are equivalent to 15 to 20% of the per capita expenditure of poor households (Alatas, 2011). This amount of benefits is calculated from the sum between fixed cash transfers and each component as seen in Table 2. For instance, a pregnant mother with toddlers will receive around IDR 5,350,000 [USD 350] per year or IDR 1,337,500 [USD 87.5] per quarter, regardless of the number of toddlers she has.

Table 2. Calculation of annual cash assistance per household

Fixed cash transfer	IDR 550.000
Cash transfer for each household with:
a. Children less than 6 years old	IDR 2,400,000
b. Pregnant or lactating mothers	IDR 2,400,000
c. Primary school children	IDR 900,000
d. Junior secondary school children	IDR 1,500,000
e. Senior secondary school children	IDR 2,000,000
f. Severe disability	IDR 2,400,000
g. Elderly	IDR 2,400,000

Source: Ministry of Social Affairs, 2022.

2.2. The context

Bima City is situated on the eastern coast of Sumbawa Island, West Nusa Tenggara Province. It is the largest city on Sumbawa Island with an estimated population of 156,224 in 2021 and a total area of 222.25 km². The city is also known as a port city which connects port cities in Eastern Indonesia and Western Indonesia. Bima City consists of five sub-districts named West Rasanae, Mpunda, East Rasanae, Raba, and Asakota. Asakota is the largest subdistrict, with a total area of 69.03 km², while West Rasanae is the smallest one, with an area of 10.14 km².

In terms of population, Raba is the largest one with 38,822 inhabitants and East Rasanae is the smallest one with only 18,706 inhabitants in 2021. Islam is by far the religion with the largest number of adherents in Bima amounting to 99.7% of the population.

In 2021, the total labor force in Bima City is 103,498 people, of which 99,811 are employed and 3,687 are unemployed.⁵ In Bima City, the service sector absorbs a comparatively large amount of labor compared to other industries. According to the National Labour Force Survey in 2021, around 67.36% of the population is employed in the service sector, followed by 21.53% in the manufacturing sector, and 11.12% in the agricultural sector. There are slightly more working men than working women with a ratio of 55:45. In terms of education level, most of the population are junior secondary graduates (31.06%), followed by university graduates (26.03%).

The poverty rate in Bima City has been declining since 2016, but it bounced back in 2021 due to the COVID-19 pandemic at 8.88%. The effort to reduce poverty cannot be separated from the expansion of FHP recipients as shown in Table 3. The number of beneficiary households kept rising from year to year with a substantial increase from 2017 to 2018 due to heavy floods in Bima, yet it declined after one year since some of the beneficiaries graduated from the program. To mitigate the effect of the COVID-19 pandemic, the central government has provided additional quotas to FHP recipients covering households with the elderly and disabilities, resulting in a significant increase in program beneficiaries in 2022.

Table 3. Number of FHP recipients in Bima City, 2016–2022

	Year
	2016	2017	2018	2019	2020	2021	2022
Number of beneficiary households	2,067	3,745	6,114	5,910	5,976	6,221	9,432

Source: Social Services of Bima City.

3. Methodology

3.1. Participant and procedures

This study is conducted using qualitative data obtained from direct, face-to-face, and semi-structured in-depth interviews with 15 FHP recipients across five sub-districts in Bima City, West Nusa Tenggara Province. The ethical clearance was provided by the Research and Innovation Institute as the Institutional Review Board in the jurisdiction of Universitas Muhammadiyah Yogyakarta under the number 56/R-LRI/XII/2022. Three informants were interviewed for each sub-district and this number was considered sufficient to capture in-depth information and reach data saturation where no new information is obtained among a homogenous population (Boddy, 2016). Different from the quantitative method, selected informants in the qualitative study do not need a large sample size so long they can provide a representative picture of the entire population.

In this study, informants were selected using some predetermined criteria, such as whether they still receive cash transfers from the FHP, can communicate clearly in Bahasa, are willing to be interviewed, reside in Bima City, and most importantly have at least one child aged less than five years. Following the strategy of Hartarto and Wibowo (2023), potential informants were identified through suggestions from the coordinator of the program facilitator in Bima City. They were purposively selected and contacted by phone for a detailed explanation of the study and to ask for their willingness to participate in a direct in-depth interview at the agreed time and place. This strategy continued until the 15^th informant.

There are some heterogeneities in terms of the initial time of FHP households receiving the funds, ranging from the last year to 10 years ago, but the majority is more than 6 years. The average age of the informant is 37 years. All the informants are Muslims. Most of the informants are housewives, relying on their husbands’ incomes, while the rests work as a peasant and shoe- repairer. Their education level varies from primary school to college degree, while most of them graduated from senior high school. Their husbands work as unskilled laborers with uncertain incomes, such as peasants, construction workers, masons, daily laborers, and motorbike drivers. The lowest monthly income earned by the FHP households is IDR 300,000 [USD 19.5], while the highest one is IDR 2,500,000 [USD 162]. In terms of per capita income, it ranges from IDR 60,000 [USD 4] to IDR 500,000 [USD 32.5]. Some FHP households are also recipients of other forms of assistance such as food vouchers amounting to IDR 200,000 [USD 13].

The FHP households in this study have at least one child aged less than five years. The amount of the grants received by the FHP households varies, depending on whether they also have school-age children in addition to their infant or toddler. The more children they have at school age and the higher their schooling level is, the more funds they will receive. The largest amount of funds received by an FHP household per three months in this study was IDR 2,000,000 [USD 129], while the smallest one was IDR 400,000 [USD 26]. Table 4 summarizes the profile of the FHP participants as key informants in this study.

Table 4. Profile of the study informants

Characteristics	Obs. (%)	Mean	Min	Max
Initial time receiving FHP (years)		6	1	10
Benefits received (IDR/quarter)			400,000	2,000,000
Age (years)		37	30	45
Family income (IDR/month)		985,000	300,000	2,500,000
Per capita		204,000	60,000	500,000
Number of household members		5	4	7
Number of children		3	2	5
Occupation
Housewives	13 (86.7)
Peasant	1 (6.7)
Shoe-repairer	1 (6.7)
Education
Primary school	2 (13.3)
Junior high school	3 (20)
Senior high school	9 (60)
College degree	1 (6.7)
Spousal education
Primary school	3 (20)
Junior high school	4 (26.7)
Senior high school	8 (53.3)
Spousal occupation
Peasants	4 (26.7)
Construction workers	2 (13.3)
Masons	2 (13.3)
Daily laborers	2 (13.3)
Motorbike drivers	2 (13.3)
Others	3 (20)

Source: Field Data Collection.

Out of five subdistricts in Bima, the FHP households generally live in a dense area with various economic backgrounds. Some of them live with their nuclear family, while some others still reside with their parents or parents-in-law. Their housing condition is relatively appropriate to be selected as FHP recipients. On average, the walls are made of bricks but remain not plastered. The paint on the wall is already faded and the floors are only cemented with no installed tiles. Most of the houses have no ceilings so they are covered with zinc roofs only. The housing environment is relatively seedy as the front yard is quite messy. The FHP households are also identified by a sticker mentioning a recipient of the MoSA assistance attached to the front door.

3.2. Instruments

This study follows Yildirim et al. (2014) and Hartarto et al. (2021) who applied a semi-structured in-depth interview method to collect data from the key informants. This was due to the time limitation of the fieldwork and to enable the flexibility of responses. The interviews were carried out using an interview guide that encompassed several exploratory issues. The questions posed to the FHP households were their profiles, their general knowledge of FHP, activities relating to FHP, how they used the assistance, their aspiration about child health, whether they often take their children to the health clinic, their feeding practice and style, and their knowledge of stunting. The type of interview questions is open-ended to gain information as much as possible (Creswell, 2013).

Before the interview, the researchers read an informed consent orally to the informant regarding the research scope and made sure that the informants understood their rights as participants. Before the prospective informant gave any approval to participate in the study voluntarily, the interviewer explained the primary questions and aims of the study. The author told the key informant that personal identity and all responses would remain confidential to keep their privacy. Informants were notified that they could stop the interview anytime if they were not willing to continue the interview, and all previous responses would be completely removed. All informants in this study were adult women who already confirmed their consent verbally. Interviews were conducted in Bahasa and audio recorded to assure clarity for transcription purposes. There was no potential harm during the interview and if the participants had any objections, they could complain to the researcher directly. The interview session ranged from 30 to 45 minutes for each informant. We consider this amount of time to be sufficient given the length of the questionnaire and the time constraints of the participants who are unwilling to be interviewed exceeding one hour. This allocated time focuses on the main questions and does not include time for building rapport with the informants and reading the informed consent.

To improve research accuracy, the triangulation method used in this study was to extract more information not only from FHP recipients but also from any involved parties in the program design such as the program facilitator and health administrator with a different interview guide. The program facilitator is responsible for ensuring that program participants can meet all the conditionalities. They are the ones who interact directly with the program participants, so they are more aware of the characteristics and attitudes of the beneficiaries. They also carry out rigorous validation and verification of whether the program participants should continue receiving the cash transfer. On the other hand, the health administrator is the one who regularly handles the health of pregnant women and monitors the child’s growth. They also provide standardized counselling to the caregiver when the children are malnourished or stunted. Moreover, the data triangulation process involved government officials relating to stunting prevention, including the Bima City Social Office and Population Control and Family Planning Service. The Social Office is responsible for program implementation and evaluation, while the Population Control and Family Planning Service actively engage in community outreach and developing treatment guidelines for stunting.

3.3. Data analysis

Data analysis in this study uses a thematic approach that identifies themes to capture narratives provided in the dataset after a thorough reading and re-reading of the transcribed data in a systematic way (King, 2004). Both deductive and inductive ways are utilized to maximize the depth of analysis in this study (Braun & Clarke, 2006). A deductive way is used as a starting point to analyze data relating to the themes that have occurred in the literature review for the study. However, some interesting information and unexpected themes may appear when analyzing data. The transcripts were coded based on sentences or phrases that were of interest. A list of the codes is then combined to form the main themes relating to the research question. The identified themes are further refined and defined to fit the broader overall picture of the data.

4. Results and discussions

Following Leroy et al. (2009), we use a program impact theory framework to help understand the qualitative evidence of the mechanisms through which FHP potentially reduces stunting in Bima City. Program impact theory is defined as a process of how a program achieves its expected impacts through its activities (Rossi et al., 2004). Figure 1 illustrates that FHP influences child nutrition through several pathways. In general, this study supports Lagarde et al. (2007) in the sense that CCT can contribute to improving children’s nutritional status through increased household income, better caloric intake from micronutrient intervention, and enhanced knowledge of mothers from exposure to health worker and program facilitator, or combination among those.

Figure 1. Pathways of which FHP affects child nutrition.

FHP beneficiaries mentioned that receiving cash transfers has provided them with additional disposable income, particularly when they were jobless. Since the beneficiaries are women as main caregivers, they would have more financial control over household resources to buy more diversified and nutritious foods (Rodgers & Kassens, 2018). Recipients of FHP were reported to purchase protein-rich food such as fish and eggs and healthier items like fruits, vegetables, and milk, especially when they still breastfed their children. Consequently, this would allow them to increase both dietary quality and quantity for their children.

Thankfully, when we have no jobs, we can afford to buy food with FHP. (Recipient 02, 35 years old, West Rasanae)

Usually (FHP) for daily needs, but we prioritize child nutrition. (Recipient 02, 35 years old, West Rasanae)

Before receiving FHP, I rarely fed my child nutritious food because I had no money. Thankfully, FHP helped me a lot financially. (Recipient 05, 33 years old, Mpunda)

I can buy more rice, eggs, soap, detergent, and fish. Then, I can buy diapers, baby oil, baby powder, and infant formula. I usually buy one box of infant formula straight away and it can last up to two months. (Recipient 03, 42 years old, Mpunda)

Buying fish and vegetables for my consumption because I still need to breastfeed my child, then buying egg and chicken for my toddler, while the rest is for rice. (Recipient 04, 35 years old, Mpunda)

Additional income alone is not enough to overcome undernutrition without any complementary interventions (Alderman et al., 2005). A more impactful effect can be realized if the improvement in a child’s food intake is combined with proper feeding practices and styles, enabling easier absorption of micronutrients (Amin et al., 2022; Batool et al., 2023). Thus, FHP involves education in health and nutrition from program facilitators with family development sessions (FDS) through monthly meetings. Health education content from program facilitators includes healthy behavior and parenting skills improvement such as caregiving and child feeding practices, which in turn increase the women’s awareness and knowledge of child health. Even, most of the recipients were already knowledgeable of stunting. These have shifted the intrahousehold preference and allocation for nutritious foods in favor of children’s needs, which contributes to stunting reduction. The topics covered in FDS also include business advice, productive economy, and household financing.

There is monthly socialization. We were taught by the facilitators how to raise our kids, and how to earn more income apart from the cash transfer. We were taught how to sell, and how to use the yard to grow crops. (Recipient 01, 47 years old, Raba)

There is socialization, counseling, monitoring, and face-to-face meetings with the program facilitators. They always remind us to go to the health clinic and have our child vaccinated. (Recipient 15, 31 years old, Asakota)

We try to change their mindset to manage what they can manage for their children’s future. As a facilitator, we act like their second husband, solving all their problems. (Program facilitator, male, 36 years old)

We highlight the importance of health and nutrition, especially for their children. If their children are sick, they will be in trouble. We also encourage them to buy their children healthy food and milk. (Program facilitator, male, 36 years old)

FHP also includes micronutrient interventions such as providing fortified food and essential supplements which potentially improve children’s anthropometric status. Micronutrient interventions even already started during pregnancy. Pregnant and lactating mothers are provided with blood supplements and some vitamins. If they weigh less than ideal, they will receive fortified biscuits. Such intervention is essential to prevent women from adverse pregnancy outcomes due to micronutrient deficiency and insufficient pregnancy weight gain (Levinson & Bassett, 2007). In addition to micronutrient interventions, those receiving FHP are also the recipients of other government programs such as non-cash food assistance⁶.

Fortified porridge and eggs. There are also vitamins provided in months two and eight, twice a year. Anthelmintic is also there. (Recipient 06, 34 years old, East Rasanae)

They receive vitamin A. There are also fortified porridge and fruits provided free by the health clinic. (Program facilitator, male, 36 years old)

There are some facilities for pregnant mothers, like vitamins before giving birth. They also receive fortified biscuits if they weigh less than ideal during pregnancy. (Recipient 12, 43 years old, West Rasanae)

Facilities for pregnant mothers include medicines, vitamins, and blood supplements. (Recipient 14, 45 years old, Asakota)

There is also non-cash food assistance, a national program that is implemented at the municipal level. (Secretary of Social Services)

One conditionality of FHP requires its recipients to comply with a monthly visit to primary health care for child growth monitoring and promotion. Their attendance is reported, and the cash transfer can be postponed if they cannot manage to visit the health clinic once a month. During the health visit, toddlers are weighed periodically, and the result is used to make mothers more aware and enhance their child’s growth. Exposure to health workers in the clinic also enhances the knowledge of the mothers about stunting. It is because each health center in Bima City provides early stimulation, detection, and intervention of the growth program against stunting (Rokx et al., 2018). Furthermore, this health-seeking behavior will increase access to and utilization of health, including vaccination and preventive care, which in turn reduce infant diseases, particularly infectious ones (Ullah et al., 2022; Zrieq et al., 2022). Furthermore, better child health will improve nutritional status. Our findings show that there is no difference between working mothers and housewives in terms of health visit since it is usually scheduled regularly per month outside the working hour.

Visiting health clinic is one of the conditionalities. Failure to do so may result in the postponement of the grant for three months. (Program facilitator, male, 36 years old)

Nearly all toddlers of FHP recipients visit the health clinic for weighing, growth monitoring, and medical check-ups. (Health administrator, female, 41 years old)

We need to visit the health clinic regularly if having an infant or toddler, and it is always monitored by the facilitator. (Recipient 10, 43 years old, Raba)

Visit health clinic regularly during the pregnancy until giving birth once in a month. (Recipient 15, 31 years old, Asakota)

Stunting is like a malnourished child, lack of growth. I heard this from a midwife at the health clinic. The midwives always explain to us about stunting in every health clinic. (Recipient 03, 42 years old, Mpunda)

For those indicated as stunted, they will receive additional supplements. They only need to bring their family card, and they will receive eggs and fortified biscuits from the health center. Since they (the toddlers) are weighed every month, the health center will stop the aid if their weight increases. (Health administrator, female, 41 years old)

DPT immunization, polio vaccine for age nine-month, and measles. All my two kids have completed vaccinations. (Recipient 06, 34 years old, East Rasanae)

In addition to FHP, the progress of stunting reduction in Bima City was accelerated by rapid improvement in hygiene and sanitation as well as community health intervention (Rokx et al., 2018). The percentage of children with access to appropriate sanitation and hygiene reached 94.18% in 2019, which increased up to 15% from the previous year.⁷ The community health intervention involves multiple parties relating to stunting. Public Health Office and Population Control and Family Planning Service, for example, have launched an application to report stunting cases in Bima City.

Some innovations are carried out by the Government of Bima City such as an application to report stunting cases. This is a collaboration project between the Public Health Office and Population Control and Family Planning Service to participate in a national competition. (Head of Public Health Division, Public Health Office)

As the main actor in stunting reduction, the Public Health Office actively socializes how to raise kids and prevent stunting for future brides and grooms. They also instruct health workers to conduct field visits for pregnant and lactating mothers to have antenatal care six times and two-time screening with medical doctors as an early stage of stunting prevention. However, some basic facilities in public health clinics still need major improvement, no specific module about stunting in the public health clinic is provided, and the budget post is only available for stunting recovery.

Every month, there are some health administrators from the clinic doing a field visit to monitor pregnancy mothers and infants/toddlers. (Recipient 15, 43 years old, Raba)

We start socialization from future brides and grooms about how to prepare for pregnancy, giving birth, and fulfilling child nutrition. (Head of Public Health Division, Public Health Office)

The initial effort we carry out for pregnant mothers is antenatal care at least six times with two times for screening with the medical doctor. We encourage them to prepare for their pregnancy and what kind of nutrition is required to prevent stunting. (Head of Public Health Division, Public Health Office)

We need more scales for infants and toddlers since the amount is not enough and the number is pretty inaccurate. (Recipient 08, 30 years old, West Rasanae)

Operational cost is the barrier. We do not have enough facilities to provide communication, information, and education to the parents and their children. (Health administrator, female, 41 years old)

We do not have any specific module for stunting, so we still use the health and nutrition module. (Program facilitator, male, 36 years old)

We need specific budget posts related to stunting so that we can solve the issue immediately each time we find a stunting case. (Secretary of Social Services)

Finally, the substantial reduction of the stunting rate in Bima City is inseparable from strong commitment and close coordination across all sectors. There are some ways forward to achieve the stunting rate by one digit as targeted by the mayor. Beyond coordination, stunting prevention always requires collaboration across institutions, and it is not solely the responsibility of the Public Health Office. Moreover, stunting prevention is related to food security and clean water sources, which involve the Food Service and Water Service, respectively, where the Regional Planning Agency acts as the leading sector in budgeting and decision-making. Universities also play a role in stunting prevention as consultants for related government institutions. Thus, the involvement of academicians with active participation from the community is instrumental in accelerating the stunting reduction in Bima City.

Clean water is influential to stunting. Food security, too. Food Service should create food innovation that we can use for socialization about nutrition like what kind of nutritious foods to provide for stunting children and pregnancy/lactating mothers. Then, the Regional Planning Agency, as a leading sector for budgetary and decision-making, must determine what needs to be done in stunting prevention. (Head of Public Health Division, Public Health Office)

This year, our mayor aims to reduce the stunting rate to one digit. Hopefully, this is achievable. (Head of Public Health Division, Public Health Office)

We have collaborated with universities by formulating policy relating to the stunting issue since a stunting locus in Bima City. So far, our program includes distributing free eggs to the local people. (Head of Population Control and Family Planning Service)

Community still perceives that stunting is government affairs. This is homework for us to socialize more in which we cannot rely on government programs without any support from the community. (Head of Public Health Division, Public Health Office)

5. Conclusions

Information on the mechanism of the CCT impact is important to improve the program’s effectiveness. This study provides qualitative evidence from Bima City as a case study on how the CCT program can contribute to reducing stunting through four mechanisms. First, the Indonesian CCT program, FHP, can influence the child nutrition of its recipients through extra income earned by the household. This subsequently can be used to buy more nutritious foods for their children. Second, micronutrient intervention can prevent pregnant mothers from being underweight and improve children’s anthropometric measures. Third, health and nutrition education from program facilitators can change the mindset of recipients and improve their knowledge about child health. Fourth, program conditionality to visit the health clinic regularly can increase exposure to health workers, which consequently improves health-seeking behavior and utilization of health services. Most importantly, the success of Bima City in stunting reduction is not only due to the FHP alone but also contextual factors such as the strong commitment of multiple government actors which enhances program effectiveness.

Overall, FHP is considered an effective intervention for preventing stunting in Bima City according to all key informants in this study. The program’s structure is notably clear: poor households receive monetary support contingent upon fulfilling specific health-related requirements. Regular and thorough monitoring of the program ensures that cash transfers are contingent on adherence to mandatory health check-ups for their children. Additionally, the program enhances recipients’ understanding of optimal child-feeding practices by providing increased interaction with healthcare professionals and facilitators. Crucially, children, who are the primary beneficiaries of the initiative, also benefit from micronutrient interventions, potentially expediting the mechanisms through which FHP positively influences child nutrition. However, it is important to note that given this study aims to explore pathways in which FHP can contribute to stunting prevention in Bima City, the conclusions drawn are potentially biased since only the success stories of program participants were revealed. It is noteworthy for future research to expose the unsuccessful part of the program.

The limitation of this study lies in the sense that it only captures the mothers’ viewpoints as the FHP recipients. We neglect the role of the fathers as the household heads. As the breadwinners, they also play an important role in taking care of the children knowing that the household decision is primarily made by them. Therefore, interpretations of this study should be made cautiously. Besides, this study cannot identify which pathway of the FHP is the most effective in influencing child nutrition since this study cannot rank the responses collected from the qualitative data.⁸ It is because our study does not focus on measuring the magnitude for each channel as in the quantitative approach and this cannot be captured qualitatively. We also do not interview the Regional Planning Agency as the key decision-maker regarding stunting prevention. Although our findings cannot be generalized to other regions, this study can provide lessons learned from Bima City on how to succeed in declining stunting through FHP supported by enabling environments.

Acknowledgments

This study would like to thank Direktorat Penelitian, Universitas Gadjah Mada and Kantor Jaminan Mutu, Universitas Gadjah Mada for their support under the Post-doctoral Program 2022. We also thank all informants for their time and for their willingness to participate in this research.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This study benefits from the internal research grants of Universitas Muhammadiyah Yogyakarta for the data collection process.

Notes on contributors

Romi Bhakti Hartarto

Romi Bhakti Hartarto is an Assistant Professor in the Department of Economics, Universitas Muhammadiyah Yogyakarta. Currently, he is a research fellow at Ungku Aziz Centre for Development Studies, Universiti Malaya. Previously, he was a consultant to the World Bank and a research assistant at Bocconi University. He obtained his Doctoral in Economics from Heriot-Watt University where he served as a Teaching Fellow. His research area focuses on family economics.

Akhmad Akbar Susamto

Akhmad Akbar Susamto is an Assistant Professor in the Department of Economics at Universitas Gadjah Mada where he serves as the head of the master's program in development economics. He is also an economist at CORE Indonesia. He obtained his doctoral degree from the Australian National University. His research interests focus on political economics, development economics, and Islamic economics.

Muhammad Rizkan

Muhammad Rizkan is a teaching staff in the Department of Entrepreneurship at Universitas Muhammadiyah Bima. He obtained his master's degree in finance from National Dong Hwa University, Taiwan. His research interest focuses on financial literacy.

Ibnu Hajar

Ibnu Hajar is a teaching fellow in the Department of Economics at Universitas Muhammadiyah Yogyakarta. He obtained his master's degree in economics from Universitas Gadjah Mada. His research interest specializes in institutional economics.

Lulu Safira

Lulu Safira is a research assistant and recently graduated from the Department of Economics, Universitas Muhammadiyah Yogyakarta.

Embarika Mostafa

Embarika Mostafa is a teaching staff at Swansea University. She obtained her doctoral degree in economics from the University of Aberdeen. Her research area focuses on development economics.

Notes

1. World Health Organization, 2021.

2. Indonesian Nutritional Status Study, Ministry of Health, 2021.

3. Family Planning and Population Control Office, Bima City, 2022.

4. OECD Development Pathways, 2019.

5. Bima Municipality in Figures, 2022.

6. Food subsidies program by the national government to increase food security through the distribution of rice in amounts equivalent to IDR 110,000 [USD 7] per month.

7. Statistics of West Nusa Tenggara Province, 2020.

8. We thank the anonymous reviewer for this comment.