The Journal of Nutrition

Community and International Nutrition

A Conditional Cash Transfer Program in the

Philippines Reduces Severe Stunting1–3
Eeshani Kandpal,4* Harold Alderman,6 Jed Friedman,4 Deon Filmer,4 Junko Onishi,5 and Jorge Avalos7
4
Development Research Group and 5Social Protection and Labor, The World Bank, Washington, DC; 6International Food Policy
Research Institute, Washington, DC; and 7Social Protection and Labor, The World Bank, Manila, Philippines

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Abstract
Background: Pantawid, a conditional cash transfer (CCT) program in the Philippines, provided grants conditioned on
health-related behaviors for children aged 0–5 y and schooling for those aged 10–14 y.
Objective: We investigated whether Pantawid improved anthropometric measurements in children aged 6–36 mo.
Methods: We estimated cross-sectional intention-to-treat effects using a 2011 cluster-randomized trial across 130
villages—65 treated and 65 control—with data collected after 31 mo of implementation. Anthropometry characteristics
were measured for 241 children in treated areas and 244 children in control areas. Health service use for children aged 6–
36 mo and dietary intake for those aged 6–60 mo also were measured. Outcome variables were height-for-age z scores
(HAZs) and weight-for-age z scores (WAZs), stunting, severe stunting, underweight, and severely underweight. Impact
also was assessed on perinatal care, institutional delivery, presence of skilled birth attendant, breastfeeding practices,
immunization, growth monitoring and deworming, care-seeking, and childrenÕs intake of protein-rich foods.
Results: Pantawid was associated with a significant reduction in severe stunting [<–3 SD from WHO standards for healthy
children; b = 210.2 percentage points (95% CI 218.8, 21.6 percentage points); P = 0.020] as well as a marginally significant
increase in HAZs [b = 0.284 SDs (95% CI 20.033, 0.602 SDs); P = 0.08]. WAZs, stunting, underweight, and severely underweight
status did not change. Concomitantly, several measures of health-seeking behavior increased significantly.
Conclusions: To our knowledge, Pantawid is one of few CCT programs worldwide that significantly reduced severe
stunting in children aged 6–36 mo; changes in key parenting practices, including childrenÕs intake of protein-rich foods and
care-seeking behavior, were concurrent. J Nutr 2016;146:1793–800.

Keywords: conditional cash transfers, transfers, child nutrition, stunting, Philippines

Introduction
In the nearly 2 decades since the introduction of conditional cash
transfers (CCTs)8 linked to participation in health services by
low-income households in the Progresa program, the impact of
such targeted social protection programs has been assessed on a
range of objectives (1). CCT programs are motivated explicitly
1
Australian Aid and the Government of Japan provided financial support to the
impact evaluation of the Philippine conditional cash transfer from which we drew
the data used in this analysis. Funding support for this study was provided by the
Consultative Group on International Agricultural Research (CGIAR) Research
Program on Policies, Institutions, and Markets.
2
Author disclosures: E Kandpal, H Alderman, J Friedman, D Filmer, J Onishi and
J Avalos, no conflicts of interest.
3
Supplemental Table 1 is available from the ‘‘Online Supporting Material’’ link in
the online posting of the article and from the same link in the online table of
contents at http://jn.nutrition.org.
*To whom correspondence should be addressed. E-mail: ekandpal@worldbank.
org.
8
Abbreviations used: ANC, antenatal care; CCT, conditional cash transfer; HAZ,
height-for-age z score; MMR, mumps–measles–rubella; NHTS-PR, National
Household Targeting System for Poverty Reduction; PhP, Philippine Pesos; PNC,
postnatal care; RCT, randomized controlled trial.
ã 2016 American Society for Nutrition.
Manuscript received April 6, 2016. Initial review completed May 4, 2016. Revision accepted June 24, 2016.
First published online July 27, 2016; doi:10.3945/jn.116.233684.
by the possibility of fostering income growth through invest-
ments in health and schooling, while at the same time addressing
existing poverty (2). In addition to their favorable impact on
poverty reduction, virtually all programs that have included
incentives to make use of health services have been able to
achieve participation in preventive health and nutrition activi-
ties (3–5). However, on average, these programs have not led
to improvements in anthropometric outcomes, although some
programs have reported a meaningful impact on selected
nutritional outcomes (3, 6–8). For example, a forest plot
analysis of 17 programs that combined CCTs and unconditional
cash transfers shows a mean impact of 0.025 on height-for-age z
scores (HAZs), an effect size that is neither statistically significant
nor biologically meaningful (7). Moreover, the 4 unconditional
transfer programs in the cited review had a larger, albeit still not
significant, impact on HAZs than the other studies.
There are many possible reasons for this disconnect between
the success of CCTs in realizing their objectives with respect to
enhancing health care and their limited impact on the goal of
achieving improvements in the nutrition of young children. First,
to our knowledge, most evaluations of CCTs have been of
1793
programs in Latin American countries with relatively low
prevalence of stunting or underweight (3, 8). Second, often the
evaluations are conducted for a relatively short time, a factor
that risks type 2 errors in studies that evaluate cumulative effects
(9). A larger impact from Progresa was noted in children who
were in the program 18 mo longer than those found in a
comparison group of participants (10). Moreover, most studies
track children <5 y of age, and thus include both children in the
period of greatest risk of growth faltering—that is, children <2 y
of age (11, 12)—and children who may be less responsive to
interventions at health care facilities. The inclusion of responsive
children in conjunction with those less responsive may mask the
program impact when the period of study does not include the
first months of the childÕs life (13). More substantive and less
methodologic reasons also are likely to account for the modest
impact of CCTs on nutritional status. In particular, the quality of
services may be a limiting factor in the translation from clinic
attendance to nutritional impact (5, 14).
The current study adds to the literature—and future system-
atic reviews—by assessing the impact of a CCT in the
Philippines, one of the 34 countries deemed to have the highest
burden of malnutrition (15). The study used a cluster-random-
ized controlled trial (RCT) design to assess the impact of a
program, the Pantawid Pamilyang Pilipino Program (or Pan-
tawid Pamilya), that was launched by the Philippine Govern-
ment in February 2008. At the time the project was launched,
34% of children <5 y of age were stunted (16). This exceeded the
stunting prevalences in the countries included in the cited
systematic reviews of CCT programs. The evaluation focused on
the impact on HAZ and stunting of young children, who were
between 6 and 36 mo of age at the time of the follow-up survey.
Methods
The Pantawid program. The Pantawid program provides cash transfers
to poor households, conditional upon investments in child education and
health, as well as use of maternal health services. Eligible poor households
were identified by the survey conducted by the National Household
Targeting System for Poverty Reduction (NHTS-PR) that used a proxy
means test, which estimated per capita household income on the basis of
observable and easily provided information, including household size and
physical dwelling conditions. Households with estimated per capita
income below the poverty line were classified as poor. From this subset of
poor households, Pantawid identified eligible households as being those
with children 0–14 y of age and/or a pregnant woman at the time of the
assessment. Poor and eligible households received a combination of health
grants and education grants every 2 mo ranging from 500 Philippine Pesos
(PhP) to PhP 1400 (;$11–$32)
household21
mo21, depending on the
number of eligible children in the household. The maximum monthly
transfer of PhP 1400 represented ;23% of beneficiariesÕ household
incomes. Besides by family size, the exact transfer amount also was
determined by the compliance behavior of the household with respect to
the health and education grants.
The health grant aimed to promote healthy practices, improve child
nutrition, and increase health care services use. Poor households with
children 0–14 y old and/or pregnant women received up to PhP 500
(;$11)
household21
mo21, conditional on fulfilling the following
requirements: 1) all children <5 y of age had to visit the health center or
rural health unit to receive age-appropriate immunization and vaccina-
tion, regular weight monitoring, and monitoring for the management of
childhood disease; 2) all pregnant women had to visit the health center
or rural health unit to undergo perinatal care, starting from the first
trimester; 3) all school-aged children (6–14 y old) had to receive
deworming pills 2 times/y; and 4) for households with children 0–14 y
old, the household grantee (mother) and/or spouse had to attend family
development sessions $1 time/mo.
1794 Kandpal et al.
A key difference between Pantawid and many other cash transfer
programs was that, in addition to growth monitoring through increased
health service use, a growth-promoting role was expected to be played by
the family development sessions. Nutrition was a major topic covered in
these sessions; parents were actively encouraged to increase childrenÕs
consumption of nutrient-rich foods, particularly dairy, and deemphasize
the consumption of packaged foods. In addition, these sessions provided
information on good parenting practices, such as exclusive breastfeeding
and prompt treatment seeking, as well as imparting information on
home remedies for basic illnesses such as diarrhea.
The education grant of up to PhP 300 ($6.50)
child21
mo21 aimed to
improve the school attendance of children 6–14 y old living in poor
households in selected areas. Households only could receive the grant for
#10 mo/y to correspond with the duration of the school year, and for #3
children in the household. Beneficiary households received the education
transfer for each child as long as the child was enrolled in primary or
secondary school and attended 85% of the school days every month.
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Direct effects of the Pantawid program studied here were determined
by estimating intention-to-treat effects that compared the effect of living in
a treated village on poor households to poor households in control villages
at the end line. In order to take into consideration regional factors,
including province-specific eligibility cutoffs, and the clustered nature of
the sample (described below), municipality fixed-effects regressions were
included. In addition, all SEs were clustered at the village level. The childÕs
age in months was included as a linear control in all specification. In this
analysis, P values < 0.05 are considered to be statistically significant,
whereas P values < 0.10 are considered to be marginally significant. The
analysis presented in this study was conducted in Stata version 13.1.
Data. The data used in this analysis are from a randomized controlled
evaluation of the Pantawid, which was stratified at the municipal level,
with randomization at the village level. Because this evaluation was a
cluster-randomized trial with treatment assignment at the village level, a
power analysis (Supplemental Table 1) was conducted with the use of 3
main outcomes of interest: monthly per capita household consumption,
school participation by children aged 6–14 y, and health facility visits by
those aged 0–5 y. In keeping with the programÕs stated objective of
improving child health and nutrition, the central research question of the
impact evaluation was to estimate the program effect on child health and
education (17). However, at the time of the power calculations, data on
child anthropometric measurements were not available for the Philip-
pines at a decentralized level; as a result, these outcomes were omitted
from the power calculations despite their being a central concern of the
impact evaluation. The 2007 Family Income and Expenditure Survey
and the 2003 National Demographic Health Survey data sets were used
as proxies for outcome mean and variance in the comparison population.
A modest hypothesized impact ensured an adequately powered study.
The power analysis used a 10% increase in household per capita
expenditures, a 7 percentage point increase in school enrollments in
children aged 6–14 y, and a 7 percentage point increase in health facility
visit rate in children aged 0–5 y. Intracluster correlation coefficients
ranged from 0.12 to 0.25, depending on the outcome of interest. These
factors combined to suggest an RCT size of 3900 households randomly
selected from 134 enumeration clusters.
The sample for the impact evaluation was selected in 3 stages (Figure 1).
First, provinces in which the program had not been introduced as of
October 2008 were enumerated. Of the 11 provinces available, 3 provinces
were excluded because of security concerns. From the remaining 8
provinces, 4 provinces were chosen to span all 3 macro areas of the country
(North, Visayas, and Mindanao). Next, in each of these 4 provinces, 2
municipalities were randomly chosen to represent the average poverty level
of areas covered by the program. Within each selected municipality, 130
villages were randomly assigned to treatment and control groups of 65
villages each. Data for the household assessment form to run the proxy
means test for beneficiary selection were fielded in the 8 RCT municipal-
ities between October 2008 and January 2009. This was followed by the
implementation of Pantawid in treated villages, with the first payment of
cash grants commencing in April 2009. The data used in this analysis were
collected in a follow-up survey from the 130 villages in October and
November 2011, allowing for a program exposure period of 30–31 mo.
 Several rounds of training were conducted before data collection to
ensure data quality, particularly of the anthropometric and dietary
intake modules. First, a training session for trainers was provided
by the officials of the Department of Social Welfare and Develop-
ment and by one of the authors who developed and field-tested the
survey instruments. Then, a 5-d training session was provided to field
supervisors by the trainers. The supervisors in turn provided an
intensive 8-d training session to enumerators; this training session was
conducted once in each province. The field supervisors were all profes-
sional surveyors and full-time staff of the survey firm, whereas enumerators
were recruited in each province and spoke the local language. The training
sessions followed the training manual developed based on international
protocols, as well as guidance from the Philippine Nutrition Council,
particularly on the collection of anthropometric data. Training also
included lectures, role playing interviews, practicing taking anthropo-
metric measurements with children, and then field testing with house-
holds with close supervision.
The current analysis was a subset of a larger project that used a study
sample of 3742 households from these 130 villages during the survey. With
an eye toward investigating potential spillovers on nonbeneficiary house-
holds, the entire study population was divided into 4 categories with the
use of the National Household Targeting Survey database as follows:

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FIGURE 1 Sample selection for the 2011 cluster-randomized impact evaluation of the Philippine Pantawid conditional cash transfer program.
The WHO reference mean was calculated by following the WHO Multicentre Growth Reference Study Group (18). Scores of .6 SDs above or
below the reference mean were dropped from the sample by following the Guide to DHS Statistics (19). DHS, Demographic and Health Surveys;
HAZ, height-for-age z score; WAZ, weight-for-age z score.

Child nutrition impact of a CCT 1795

 TABLE 1 Baseline data show that household characteristics were not significantly different between
the 1418 category 1 treatment and control households1

Overall Control Treatment

Baseline survey variables sample group group SE P value2 P3

n 1418 704 714

Household composition
Members, n 5.7 5.7 5.7 0.1 0.7 0.9
Children aged #5 y, n 1.1 1.1 1.1 0.1 0.5 0.7
Children aged 6–14 y, n 1.7 1.6 1.7 0.1 0.9 0.6
Primary occupation farming and livestock, % of households 71.3 69.4 73.1 0.0 0.3 0.8
Household head educational attainment, % of households
No grade completed 9 8.5 9.5 0.2 0.6 0.8
Some elementary school 41 42 40 0.0 0.4 0.4
Completed elementary school 21.8 21.8 21.8 0.0 1 0.9

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Some high school 12 12.8 11.2 0.0 0.2 0.6
High school graduate 11.1 10.4 11.9 0.0 0.3 0.8
Some college 3.7 3.3 4 0.0 0.4 0.8
College graduate 1.8 1.7 1.9 0.0 0.6 0.9
Attendance in school, % of households
Attendance of children aged 6–11 y 9.0 9.0 9.0 0.0 1.0 0.9
Attendance of children aged 12–14 y 8.0 8.0 8.0 0.0 0.4 0.3
Housing amenities, % of households
Strong roof materials4 26.7 27 26.4 0.0 0.9 0.5
Light roof materials4 54 52.7 55.3 0.0 0.5 0.9
Strong wall materials5 16.4 16.9 15.9 0.0 0.8 1
Light wall materials5 47.2 46 48.4 0.0 0.6 0.6
Owns a house and lot 32.2 32.9 31.5 0.0 0.7 0.2
House has no toilet 42.4 43.3 41.4 0.0 0.6 0.8
Household assets, % of households
Has electricity in house 41 39.6 42.4 0.0 0.5 0.5
Owns a television 17.6 17.7 17.4 0.0 0.9 0.6
Owns a stereo or compact disk player 10.1 10.5 9.6 0.0 0.5 0.8
Owns a telephone or cellphone 6.1 5.8 6.4 0.0 0.6 1
Owns a motorcycle 2 2.2 1.7 0.0 0.3 0.9
1
Values are means or percentages and SEs.
2
Data reported are P values from pairwise comparisons of means with the use of t tests.
3
Data reported are P values from the pairwise comparisons of means with the use of Kolmogorov-Smirnov tests.
4
Strong roof materials included galvanized iron, aluminum, tile, concrete, brick, stone, wood, and asbestos. Light roof materials included
grasses or palm tree leaves.
5
Strong wall materials included tile, concrete, brick, stone, wood, and plywood. Light wall materials included grasses or palm tree leaves.

d Category 1 households: 1418 poor households, i.e., households
whose estimated per capita income fell below the poverty line, and
that also had children aged 0–14 y and/or a pregnant mother at the
time of the household assessment. This was the category eligible for
the cash transfer. The sample of 1418 households was randomly
assigned to 714 treated households and 704 control households for
their lives, and 244 children in the same age range from poor
households in control areas.
d Category 2 households: 1137 nonpoor households with estimated
per capita incomes above the poverty line, but that had children
aged 0–14 y and/or a pregnant mother.
d Category 3 households: 556 poor households without children aged

the impact evaluation. At the time of the data collection in 2011, in 0–14 y or a pregnant mother.
these 714 treated households there were 241 children <3 y of age d Category 4 households: 631 nonpoor households without children

who could have been exposed to the program in the first 1000 d of aged 0–14 y or a pregnant mother.

TABLE 2 Program impact on child anthropometric measurements for treated children aged 6–36 mo
compared with children of the same age range from control villages1

WAZ HAZ Underweight Stunted Severely underweight Severely stunted

n 390 351 390 351 390 351

Program impact 0.140 0.284* 22.570 23.768 1.075 210.189**
95% CI 20.161, 0.438 20.034, 0.600 211.980, 6.839 213.830, 6.294 24.720, 6.871 218.769, 21.607
Control group 21.251 21.903 28.723 49.701 8.511 23.952
1
Values for the control group are means or prevalences. WAZs and HAZs are in SDs from the WHO reference mean (18); underweight, stunted,
severely underweight, and severely stunted are prevalences. Data were analyzed with the use of intention-to-treat analysis. All regressions
include linear controls for age in months, the childÕs sex, and municipality fixed effects. SEs are clustered by village. *P , 0.1, **P , 0.05.
HAZ, height-for-age z score; WAZ, weight-for-age z-score.

1796 Kandpal et al.

TABLE 3 Pantawid impact on use of maternal health services for pregnancies in treated villages compared with control villages from
the start of the program (children #36 mo old)1

Whether ANC was Number of times Whether PNC was received Whether birth was in presence Where delivery
received $4 times ANC was received within 24 h of a skilled birth attendant was institutional

n 462 462 464 469 469

Program impact 7.648 0.596* 10.215** 2.388 1.757
95% CI 23.148, 18.443 20.088, 1.280 0.609, 19.821 29.644, 14.419 27.803, 11.317
Control group 54.911 4.147 29.596 44.934 29.075
1
Values for the control group: prevalences of ANC or PNC received, mean number of times ANC received, and rates of delivery care variables. Data were analyzed with the use of
intention-to-treat analysis. All regressions include linear controls for age in months and municipality fixed effects. SEs are clustered by village. *P , 0.1, **P , 0.05. ANC,
antenatal care; PNC, postnatal care.

The estimated program impact reported here compared treated and previous week. Our sample of children aged 6–60 mo included data on
control villages within Category 1 households (Figure 1). The survey data the egg and fish consumption of 436 treated children and 406 control

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include complete HAZ data on 194 of the 241 treated children <36 mo of
age and 178 of the 244 control children <36 mo of age. Complete weight-
for-age data were collected for 204 of the 241 treated children <36 mo of
age, and 189 of the 244 control children <36 mo of age. Anthropometric z
scores were calculated on the basis of the WHO growth standard (18).
Scores of >6 SDs above or below the reference mean were dropped from
the sample (19). This trimming resulted in the dropping 10 of the 194
treated children and 11 of the 178 control children from the HAZ
regressions, and the dropping of 2 of the 204 treated children and 1 of the
189 control children from the weight-for-age regressions. Stunting was
measured as HAZ <22 SD and severe stunting as <23 SD, on the basis of
the WHO Child Growth Standards (18).
In addition, women with $1 pregnancy in the previous 36 mo were asked
about their timing and frequency of use of antenatal care (ANC) and
postnatal care (PNC), where they gave birth, and whether a skilled birth
attendant was present at the delivery. To ensure comparability with the
anthropometric sample, and to minimize measurement error, we focused on
health care behaviors and parenting practices for children aged 6–36 mo; this
trimming yielded a sample of 238 children from treated households and 224
children from control households for ANC and PNC use, whereas for
institutional delivery and skilled birth attendance, we had 242 treated and
227 control observations. With the use of data on how soon after birth
breastfeeding was initiated, and the time during which the child was
exclusively breastfed (including zeroes), we constructed indicator variables
for whether breastfeeding was initiated within 24 h of birth, and whether the
child was breastfed exclusively for $6 mo. As above, we focused on children
aged 6–36 mo, which gave us a sample of 209 children from treated
households and 192 children from control households for prompt initiation of
breastfeeding, and 162 treated and 153 control for exclusive breastfeeding.
Furthermore, women with $1 child <36 mo of age were asked about health
service use for the child, including regular growth monitoring, deworming,
receipt of the mumps–measles–rubella (MMR) vaccine, and care-seeking for
any fever, cough, or diarrheal illness in the previous 2 wk. Our sample of
children aged 6–36 mo included 231 treated children and 236 control children
for growth monitoring, 237 treated children and 235 control children for
deworming, 216 treated children and 212 control children for MMR, and 229
treated children and 227 control children for care-seeking.
Finally, women with $1 child <60 mo of age were asked whether
each child in that age range consumed any eggs, dairy, meat, or fish in the
children, as well as the dairy intake of 433 treated children and 399
control children and meat consumption of 437 treated children and 406
control children.
Before estimating program impact, we first conducted a test to
determine whether random assignment was successful and, therefore,
whether the differences observed between households in Pantawid villages
and control villages could be treated as causal. This test compared the
mean values of available baseline characteristics of households in control
villages with the mean baseline characteristics of households in treated
villages, and tested for significance of differences with the use of t tests.
Data collected from the NHTS-PR before the implementation of Pantawid
were used. Village-level averages were calculated for a range of indicators
(population, poverty incidence, household composition, asset ownership,
housing amenities, education achievements, school enrollment, and visits
to health centers). Note that baseline values of the outcome variables
studied in this paper were not collected by the NHTS-PR and, as such,
were not reported in the baseline characteristics. Distributions of these
indicators for the treatment and control groups were compared with the
use of t tests and Kolmogorov-Smirnov tests.
The data analyzed here were collected as part of an evaluation requested
from The World Bank by the Philippine Department of Social Welfare and
Development to support its scheduled rollout of the program. The evaluation
was designed as an integral part of the monitoring and evaluation of this
program, and was intended to inform on the effectiveness of the program
and guide its scale up. The World Bank designed the impact evaluation.
However, data collection was conducted by an independent contracted third
party, which obtained oral consent from all interviewees, and only suitably
anonymized data were released for analysis. These data were used by the
authors for the analysis presented here. All authors of this manuscript were
associated with The World Bank and had no connection with the Philippine
Department of Social Welfare and Development or the firm that collected the
data.
Results
Sample characteristics. Results of the test of balance in
observable characteristics between control and treatment vil-
lages, which used available baseline data from the NHTS-PR,

TABLE 4 Pantawid impact on use of health services for children aged 0–36 mo in treated villages compared with control villages1

Whether child received regular Whether child took Whether child received Whether parent sought treatment for the child for
weighing according to age deworming pills MMR vaccination any illness in the previous 2 wk

n 467 472 428 456

Program impact 6.558** 1.825 8.641* 9.830**
95% CI 1.316, 11.801 26.267, 9.918 20.460, 17.744 0.179, 19.481
Control group 10.593 34.894 30.660 41.850
1
Values for control group are rates. Data were analyzed with the use of intention-to-treat analysis. All regressions include linear controls for age in months, the childÕs sex, and
municipality fixed effects. SEs are clustered by village. *P , 0.1,**P , 0.05. MMR, mumps–measles–rubella.

Child nutrition impact of a CCT 1797

are presented in Table 1. Neither the t test, which assumes a

Values for the control group are rates. Data were analyzed with the use of intention-to-treat analysis. All regressions include linear controls for age in months, the childÕs sex, and municipality fixed effects. SEs are clustered by village. *P , 0.1,
6–36 mo were breastfed
Whether children aged
normal distribution, nor the Kolmogorov-Smirnov test, which

exclusively for 6 mo

216.216, 5.563
does not, yielded P values <0.1, suggesting that none of the 24

25.326

57.516
pairwise comparisons presented SDs between treatment and

409
control villages. The lack of any significant differences between
control and treatment villages at baseline indicated that random
assignment was successful, i.e., that treatment and control
groups were balanced in 2008.

Program effect on anthropometric outcomes. Intention-to-

treat estimates (Table 2), obtained from specifications that include

Whether breastfeeding was

initiated within 24 h of birth
(children aged 6–36 mo)
linear controls for age, indicate that Pantawid tended to increase
HAZs (P = 0.08) and significantly decreased severe stunting in 6- to

27.409, 8.485
36-mo-old children, the oldest of whom would have been 5 mo old

0.538

74.479
401
at the time of program rollout. The coefficient estimate on height
for age corresponds to an increase of 0.28 SDs in HAZ at follow-up

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relative to a control HAZ of 21.9 SDs. The change in severe
stunting in children aged 6–36 mo from poor households in treated
villages was a 10.2 percentage point significant decrease from the
mean rate of 24% in control villages. Results are robust to the use
of quadratic or no control for child age. No other statistically

Whether child consumed

(children aged 6–60 mo)

significant impact was found for other measures of malnutrition,

fish in previous week

although the coefficient estimates also are negative for indicators of

22.332, 8.115
wasting and underweight status.

2.891

85.222
842
Next, we considered some behavioral changes that may
explain the decrease in severe stunting. Consistent with the
program conditions for pregnant women, women in treated
villages received ANC 4.7 6 2.7 compared with 4.15 6 3.9

Program impact on parenting practices in treatment villages compared with control villages1
times for women in control villages, an increase that is
marginally significant (P value of 0.09) (Table 3). Similarly,
39.4% 6 48.9% of women in Pantawid villages received PNC
Whether child consumed

(children aged 6–60 mo)

meat in previous week
within 24 h of delivery, reflecting a significant increase of 10.2
percentage points over the control mean usage of 29.2% 6

25.151, 10.552
45.7%. However, we did not find evidence that the program

2.700

0.500
843
improved institutional delivery or skilled birth attendance,
although one of the program conditions was for deliveries to
occur at a health facility or, at a minimum, to be assisted by a
doctor or midwife.
However, poor children aged 0–36 mo in treated villages were
more likely to have received age-appropriate health services in the
previous 6 mo. These increases in health services use included
Whether child consumed

(children aged 6–60 mo)

dairy in previous week

regular growth monitoring (an increase of almost 7 percentage

20.505, 14.239

points), the receipt of an MMR vaccination (a marginally significant

6.867*

24.812

increase of 8.7 percentage points; P = 0.06), and treatment-seeking

832

for fever, cough, and diarrheal disease (increase of 9.8 percentage

points relative to a control mean of 41.8%; the incidence of fever,
cough, and diarrheal illness itself was not significantly different
between treatment and control arms) (Table 4). In addition, infant
and young child feeding practices also appear to have been affected:
children aged 6–60 mo in treated areas were 8.2 percentage points
Whether child consumed

more likely to consume eggs than were those aged 6–60 mo from
(children aged 6–60 mo)
eggs in previous week

control areas. A marginally significant (P = 0.07) increase also was

1.516, 14.901

observed in dairy consumption: children aged 6–60 mo in treated

8.211**

70.370
842

areas were 6.9 percentage points more likely to have consumed

dairy in the previous week, relative to a control mean of 24.8% of
children aged 6–60 mo. However, no changes were found in the
reported consumption of meat or fish, nor in breastfeeding practices)
(Table 5).
Program impact
TABLE 5

Control group

Discussion
**P , 0.05.
95% CI

Since its program launch in 2008, Pantawid has scaled up

rapidly and has become the cornerstone of the Philippine
n

1798 Kandpal et al.

GovernmentÕs social protection strategy. By December 2014, the
program had ;4.45 million active beneficiary households. As
indicated in this study, the program had achieved a reduction in
severe stunting in its beneficiaries by late 2011. There have been
a few other quasi-experimental or matching studies of CCTs that
have reported a significant impact on stunting of a similar
magnitude since the systematic reviews cited (20, 21). However,
the current program assessment differs in that it provides
evidence based on an RCT from a country among those with the
highest burden of stunting.
This improvement may have been accomplished through
$1 potential pathway. Indeed, implicit in the program are
2 main potential pathways, plus their interaction. First, the
increased income from the cash transfer may have facilitated
an improvement in diet diversity. Second, the conditions, by
promoting attendance at family development sessions, timely
perinatal care, and regular growth monitoring and health
service use, may have led to increased diet diversity and clinical
counseling. Finally, the information provided through the
enforcement of program conditions may have combined with
the additional cash to result in greater investments in childrenÕs
welfare and improved health and sanitation (Figure 2). These 2
main pathways plus their interaction may have contributed to
the observed 8.2–percentage point increase in egg consumption
in children aged 6–60 mo, as well as a measured increase in dairy
consumption. These and other unmeasured changes in diet
diversity and quantities consumed could be correlated with the
improvements in measured height for age; intake of protein,
relative to other macronutrients, has been demonstrated to
increase child height (22). Similarly, parenting education provided
during the programÕs family development sessions and clinical
counseling provided during growth monitoring visits also may
have affected child care practices, and through this pathway
FIGURE 2 Potential pathways of impact for the Philippine Pantawid
conditional cash transfer program.
influenced anthropometric measurements. It is plausible that all 3
factors—food, health, and care—contributed to the improvement
in growth assessed by height for age; even if each change
individually had a small impact, collectively, the set of dietary and
behavioral changes could influence stunting prevalence. The
research design, however, was not set up to isolate the relative
contribution of these different pathways.
It is also noteworthy that most of the children studied were in
the program for the entirety of their young lives. Even those who
were born before the program rollout were <6 mo of age at the
time. Moreover, the data were collected after 31 mo of program
implementation. Thus, the study was able to observe the
cumulative impact up to and beyond the age at which the risk
of stunting was most likely to occur (11), a period in which
stunting is associated with outcomes later in life (23). Finally, by
focusing exclusively on children who were in this critical age
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period, the analysis avoided the risk of biasing results down-
ward, as might occur if less responsive older children were
aggregated in the sample with the more vulnerable age group.
The intention-to-treat analysis used here presented the most
relevant results, because 15% of those eligible in the treatment
villages reported that they did not participate. We do not know
what accounts for the decision to take up the program or,
conversely, noncompliance. This rules out an opportunity to obtain
an unbiased estimate of the treatment on the treated. Similarly,
although it is clear that the fact that 7% of the sample in control
communities that report participation in the project slightly biased
the estimated impact toward zero, we did not account for this
minor crossover. Thus, the intention-to-treat estimates were lower
bounds on the true effect of the program on the treated.
Although we lack the data to determine conclusively the causes
of PantawidÕs success at reducing severe stunting and at improving
HAZs, this success may have been due to differences in the
implementation of the CCT, or, indeed, the baseline level and
severity of malnutrition. Many countries that implement CCTs
conditioned on growth monitoring also provide additional
nutritional interventions as part of early childhood development
interventions; however, it may be that the implementation of any
such additional support was more uniform in the Philippines,
leading to a larger impact of the CCT. Finally, the gains in
childrenÕs egg and dairy consumption, not often documented by
evaluations of CCTs, also may have played a role in the HAZ
gains from Pantawid. This study of the national Philippine cash
transfer program, Pantawid, provides evidence of a promising
impact on child nutrition that supports the GovernmentÕs
decision to scale up the transfer. In addition, the results speak
to the literature on the limited association between cash
transfers and child nutrition, and show that cash transfers can,
in fact, significantly decrease child stunting. Finally, this study
provides evidence to inform the design of policies that aim to
reduce child malnutrition.
Acknowledgments
We thank Corazon Juliano-Soliman, Alicia R Bala, Mateo G
Montaño, and Parisya Taradji of the Philippine Department
of Social Welfare and Development for their collaboration
and helpful feedback during the instrument development.
We also thank Deanna Olney, Aleksandra Posarac, and Marie
Ruel for their helpful comments on the analysis. EK, HA, JF,
DF, and JO designed the research; EK and HA wrote the
paper; EK, JF, JO, and JA conducted the research; EK and JA
analyzed the data; and EK had primary responsibility for
the final content. All authors read and approved the final
manuscript.
Child nutrition impact of a CCT 1799
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