Multiple Micronutrient Supplementation Reduces Anemia and Anxiety in Rural China's Elementary School Children
Despite growing wealth and a strengthening commitment from the government to provide quality education, a significant share of students across rural China still have inadequate access to micronutrient-rich regular diets. Such poor diets can lead to nutritional problems, such as iron-deficiency anemia, that can adversely affect health, attention and cognitive ability. The overall goal of this paper is to assess the impact of multiple micronutrient supplementation on anemia and anxiety among students in poor areas of rural China. We report on the results of a randomized control trial (RCT) involving over 2700 fourth grade students, mostly aged 9 to 12, from 54 randomly-chosen elementary schools in 8 of the poorest counties in Shaanxi Province in China’s poor northwest region. The design called for random assignment of schools to one of two groups. One group received a daily multivitamin with mineral supplements, including 5 milligrams of iron, for 5 months while the other group was a non-intervention, control group. Anemia was defined as < 120 g/L. We found that 42.4 percent of students were anemic at baseline In the schools that received the multivitamins with mineral supplements, Hb levels rose by more than 1.7 g/L over the control schools. The test for anxiety showed that students that received the multivitamin with mineral supplements also improved significantly. Overall, these results should encourage further research on the interaction between nutrition and mental health in a development context.
Policy Related Research - REAP 2013
Official Policy Briefs
(Submitted to China’s State Council)
Do You Get What You Pay For with School-Based Health Programs? Evidence from a Child Nutrition Experiment in Rural China
This study uses a randomized controlled trial of a school-based anemia reduction program in rural China to examine how increased school emphasis on health promotion affects academic performance. Although education and health promotion are complementary functions of schools, they do compete for finite school resources. We compare the effects of a traditional program that provided only information about anemia and subsidies to an otherwise identical program that included performance incentives for school principals based on school-level anemia prevalence. By the end of the trial, exam scores among students who were anemic at baseline improved under both versions of the program, but scores among students in the incentive group who were healthy at baseline fell relative to healthy students in the control group. Results suggest that performance incentives to improve student health increase the impact of school-based programs on student health outcomes, but may also lead to reallocation of school resources.
Text Messaging and Its Impacts on the Health and Education of the Poor: Evidence from Field Experiments in Rural China
There is little evidence showing whether health information transmitted via text messages can change health and educational outcomes. We conducted a randomized field experiment involving 900 primary students in rural China to study whether a health education campaign conducted via text message could affect caregiver knowledge or student outcomes. When caregivers received both weekly health messages and monthly quiz questions (testing retention of the information conveyed in the weekly messages), caregiver knowledge improved and students experienced gains in both health and academic performance. When caregivers received weekly health messages only, there was no impact on caregiver knowledge or student outcomes.
Scott Rozelle on How Agriculture Vitalized China's Economy
China’s commitment to agricultural development over the last thirty years has dramatically transformed the country’s economy. Rural income per capita has risen an astounding 20 times after 30 prior years of stagnation. Its poverty rate (US$1.25/day) has dropped from 40 percent to less than five, and 350 million rural people between the ages of 18-65 are now working in the industrial or service sector, enjoying rising wages and new economic opportunities.
This rapid transformation is largely the result of three key agricultural policy decisions: putting land in the hands of farmers, market deregulation, and major public investment in the agricultural sector. Although China must now contend with extreme inequality, high levels of pollution, and an aging farming sector there are still lessons to draw from China’s experience that could hasten the transformation of other developing countries.
China expert and agricultural economist Scott Rozelle broke these lessons down at FSE’s fourteenth Global Food Policy and Food Security Symposium Series last week, opening with an underlying theme of the series.
“Growth and development starts with agriculture,” said Rozelle. “Agriculture provides the basis for sound, sustained economic growth needed to build housing, invest in education for kids, start self-employed enterprises, and finance moves off the farm.”
To prove this point he referenced China’s ‘lost decades’ (1950s-1970s) when 80 percent of the population lived in the rural sector and relied on communal, subsistence agriculture. Poor land rights, weak incentives, incomplete markets and inappropriate investments left the average rural farmer poorer at the end of 70s than they were in the 50s with almost no off-farm employment growth.
So what changed? Incentives, market deregulation and strategic investments by the state were key.
Creating the right incentives
In 1978 the Chinese government broke the communes down into small “family farms” such that every rural resident was allocated a small parcel of land. A family of five farmed an area the size of a football field. While they did not own nor could sell the land, they had the right to choose what crops and inputs they used and the right to the income generated from their land.
“Incentives are important, and can be enough in the short run,” said Rozelle. “Hard work led to money in the pockets of farmers and China was off.”
“Every two and half years China added another California in term of agriculture,” said Rozelle.
Between 1979 and 1985 productivity for wheat, maize, and rice went up 50 percent using the same amount of labor, land and inputs. Agriculture across the spectrum has grown at an astounding rate of 5 percent since 1988 (about four times the population growth rate). Livestock and fisheries have grown even faster – accounting for most of the output of the agricultural sector by 2005.
Income growth from farming enabled family members to begin to seek work off the farm. Between 1980 and 2011, off-farm work increased 71 percent with more than 90 percent of households reporting that at least one family member worked off the farm.
Increasing efficiency through liberalization and investment
Another key policy decision was China’s commitment to market liberalization and investment in public goods.
“Markets can be an effective, pro-poor tool of development,” said Rozelle. “A remarkable partnership is formed when you let farmers do production and government do infrastructure…let markets guide decisions.”
The government dismantled state-owned grain trading companies and deregulated trading rules. Prices were set once a week the same day across China to better integrate markets, and eventually prices for major crops closely mirrored those of world prices. Villages began specializing in crops and livestock and incomes of the poor increased. By not providing government input subsidies (e.g, pesticides, fertilizers), traders were incentivized to participate in the market.
“Giving land to farmers and letting the private sector emerge is an easy thing for governments, even without a lot of money, to do,” said Rozelle.
The government provided more indirect market support by publicly investing in better roads, communications, and surface water irrigation. Groundwater was left to the private sector. There were no water or pumping fees nor subsidies for electricity, keeping it completely deregulated. As a result, 50 percent of cultivated land in China is irrigated, compared to 10 percent in the US and only four percent in sub-Saharan Africa.
Finally, China has invested heavily in agricultural research and development (R&D). One percent of China’s agricultural GDP is now invested in agricultural R&D while US investment has fallen over time. US$2 billion alone goes to investments in Chinese biotechnology.
Despite major investment, China only has one major success story to show for so far. The introduction of Bt cotton led to a significant drop in pesticide use (with important health benefits for farmers), and drop in labor and seed price; resulting in a huge 30 percent increase in net income.
“GM technology benefits exist but big policy decisions still need to be made in the face of much resistance both in China and elsewhere in the world on its application,” said Rozelle.
Status of China’s economy
China has largely solved the country’s macro-nutrient food security problem at the household level (>3000 Kcal/day/person) and millions have been lifted out of poverty. Practically all 16-25 years old are now working off the farm.
“This is a real transformation, and one that could not have happened without a major investment in agriculture,” said Rozelle.
While China’s agricultural accomplishments have been major, Rozelle recognizes the system is far from perfect. For starters, there are serious food safety concerns due to lack of traceability. An astounding 98 percent of Beijing consumers think their food is tainted, said Rozelle.
Water is being pumped like crazy and farmers are aging. The younger generation is neither willing nor interested in following in their parents’ farming footsteps. To make up for a labor deficit farmers are applying huge amounts of fertilizer on their land with serious environmental consequences. As a result of changing demographics and an increasing demand for meat, fish, fruits and vegetables, China is likely to be a net importer of food in the long run.
China also faces major urban and rural inequality issues. Even though wages have risen, inequality has not fallen, largely a result of China’s decision not to privatize rural land.
“Rural people have no assets on which to build wealth while urban people were given assets in the form of housing,” said Rozelle. “Housing prices in major cities in China now rival those in the Bay Area!”
The Chinese government fears losing control of the land, but this comes at a price of less individual incentive to invest and inability to build larger farmers. As agricultural growth slows, Rozelle worries high levels of inequality could lead to instability.
Adding fuel to the fire, investment in rural health, nutrition, and education remains far from sufficient. Only 40 percent of the rural poor go to high school resulting in 200 million people who can barely read or write.
“What’s going to happen in 20 years when low skill manufacturing jobs move to other countries?” asked Rozelle. “The rural, uneducated poor are going to become unemployable.”
China’s record leaves room for improvement, but presents a strong case for supporting smallholder agriculture. For those countries emerging out of their own lost decades, smallholder agriculture should remain a primary focus of investment and development.
Eggs versus Chewable Vitamins: Which Intervention Can Increase Nutrition and Test Scores in Rural China?
Background. Despite growing wealth and a strengthening commitment from the government to provide quality education, a significant share of students across rural China still have inadequate access to micronutrient-rich regular diets. Such poor diets can lead to nutritional problems, such as iron-deficiency anemia, that can adversely affect attention and learning in school. Large scale policies in Northwestern China have attempted to tackle these nutritional problems using eggs. The overall goal of this paper is to assess the impact of the government’s egg distribution program by comparing the effect on anemia rates of an intervention that gives students an egg per day versus an intervention that gives students a chewable vitamin per day. We will also assess whether either intervention leads to improved educational performance among students in poor areas of rural China. To meet this goal, we report on the results of a randomized controlled trial (RCT) involving over 2,600 fourth grade students from 70 randomly-chosen elementary schools in 5 of the poorest counties in Gansu Province in China’s poor Northwest region. The design called for random assignment of schools to one of two intervention groups, or a control group with no intervention. One intervention provided a daily chewable vitamin, including 5 milligrams of iron. The other mimicked the government policy by providing a daily egg. According to the findings of the paper, in the schools that received the chewable vitamins, hemoglobin (Hb) levels rose by more than 2 g/L (over 0.2 standard deviations). The standardized math test scores of students in these schools also improved significantly. In schools that received eggs, there was no significant effect on Hb levels or math test scores. Overall, these results should encourage China’s Ministry of Education (MOE) to look beyond eggs when tackling nutritional problems related to anemia in an education setting.
Parental Training, Anemia and the Impact on the Nutrition of Female Students in China’s Poor Rural Elementary Schools
In this paper we report the results of a randomized controlled trial designed to measure the impact of a parental training program on the nutritional status of primary school students in rural Shaanxi Province, in Northwest China. Using hemoglobin (Hb) levels as the outcome variable, we first measure the overall impact of a nutritional training program, then measure the impact separately by gender. We use both descriptive and multivariate analyses.
The results for the descriptive and econometric results were robust and consistent with the literature. Overall, we find no impact on students’ Hb levels when we trained their parents about undernutrition and anemia. In both the descriptive and multivariate results, there was no difference in the change of Hb levels between control and treatment students. Parents in the treatment group did learn more about anemia than parents in the control group, but this increased knowledge did not lead to sharp changes in behavior, in general. We did find, however, that there was a measurable impact of parental training on the Hb levels of female students. In both the descriptive and econometric results we found that the Hb levels of female students rose more than that of male students, and that this difference was statistically significant. We conjecture that the parents of female students may have recognized from the training that they were not providing their daughters with sufficient nutrition. Our data show that parents in the treatment group responded by increasing the daily provision of meat, fish, eggs and beans, relative to parents of girls in the control group.
China and Africa: Are there Lessons for Development?
The lost decades for China in the 1950s, 1960s and 1970s look remarkably like the lost decades of Africa in the 1980s and 1990s. Poor land rights, weak incentives, incomplete markets and inappropriate investment portfolios. However, China burst out of its stagnation in the 1980s and has enjoyed three decades of remarkable growth. In this talk Rozelle examines the record of the development of China’s food economy and identifies the policies that helped generate the growth and transformation of agriculture. Incentives, markets and strategic investments by the state were key. Equally important, however, is what the state did not do. Policies that worked and those that failed (or those that were ignored) are addressed. Most importantly, Rozelle tries to take an objective, nuanced look at the lessons that might be learned and those that are not relevant for Africa. Many parts of Africa have experienced positive growth during the past decade. Rozelle examines if there are any lessons that might be helpful in turning ten positive years into several more decades of transformation.
Scott Rozelle (main speaker). Scott Rozelle is the Helen F. Farnsworth Senior Fellow and the co-director of the Rural Education Action Program in the Freeman Spogli Institute for International Studies at Stanford University. His research focuses almost exclusively on China and is concerned with: agricultural policy, including the supply, demand, and trade in agricultural projects; the emergence and evolution of markets and other economic institutions in the transition process and their implications for equity and efficiency; and the economics of poverty and inequality, with an emphasis on rural education, health and nutrition.
Alain de Janvry (commentator). Alain de Janvry is an economist working on international economic development, with expertise principally in Latin America, Sub-Saharan Africa, the Middle-East, and the Indian subcontinent. Fields of work include poverty analysis, rural development, quantitative analysis of development policies, impact analysis of social programs, technological innovations in agriculture, and the management of common property resources. He has worked with many international development agencies, including FAO, IFAD, the World Bank, UNDP, ILO, the CGIAR, and the Inter-American Development Bank as well as foundations such as Ford, Rockefeller and Kellogg. His main objective in teaching, research, and work with development agencies is the promotion of human welfare, including understanding the determinants of poverty and analyzing successful approach to improve well-being and promote sustainability in resource use.
Bechtel Conference Center
Scott Rozelle
Encina Hall East, E404
Stanford, CA 94305-6055
Scott Rozelle is the Helen F. Farnsworth Senior Fellow and the co-director of Stanford Center on China's Economy and Institutions in the Freeman Spogli Institute for International Studies and Stanford Institute for Economic Policy Research at Stanford University. He received his BS from the University of California, Berkeley, and his MS and PhD from Cornell University. Previously, Rozelle was a professor at the University of California, Davis and an assistant professor in Stanford’s Food Research Institute and department of economics. He currently is a member of several organizations, including the American Economics Association, the International Association for Agricultural Economists, and the Association for Asian Studies. Rozelle also serves on the editorial boards of Economic Development and Cultural Change, Agricultural Economics, the Australian Journal of Agricultural and Resource Economics, and the China Economic Review.
His research focuses almost exclusively on China and is concerned with: agricultural policy, including the supply, demand, and trade in agricultural projects; the emergence and evolution of markets and other economic institutions in the transition process and their implications for equity and efficiency; and the economics of poverty and inequality, with an emphasis on rural education, health and nutrition.
Rozelle's papers have been published in top academic journals, including Science, Nature, American Economic Review, and the Journal of Economic Literature. His book, Invisible China: How the Urban-Rural Divide Threatens China’s Rise, was published in 2020 by The University of Chicago Press. He is fluent in Chinese and has established a research program in which he has close working ties with several Chinese collaborators and policymakers. For the past 20 years, Rozelle has been the chair of the International Advisory Board of the Center for Chinese Agricultural Policy; a co-director of the University of California's Agricultural Issues Center; and a member of Stanford's Walter H. Shorenstein Asia-Pacific Research Center and the Center on Food Security and the Environment.
In recognition of his outstanding achievements, Rozelle has received numerous honors and awards, including the Friendship Award in 2008, the highest award given to a non-Chinese by the Premier; and the National Science and Technology Collaboration Award in 2009 for scientific achievement in collaborative research.
Stanford Center on China’s Economy and Institutions
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Teaming Up to Learn How to Overcome Anemia: Nutritional Education and Mobile Messaging Design for Household Engagement
This study seeks to understand whether developing an innovative curriculum kit that will supplement health instruction for 3rd to 6th grade students and teachers in underdeveloped areas of rural China can also be delivered to parents in a set of pilot schools will: improve nutrition and the knowledge of teacher, students and parents about nutrition; reduce the level of anemia; and increase educational performance. The project will also study how to best deliver the message and keep parents accessing the information so they can act on it. The work will entail developing and examining the effectiveness (on the same outcome variables we investigate for the supplemental health class) of ways to use new technologies: mobile phones and postal mailings (for those without mobile phones) to follow up with parents and try to reinforce the message so they put it into action.
Walter P. Falcon Lounge
Scott Rozelle
Encina Hall East, E404
Stanford, CA 94305-6055
Scott Rozelle is the Helen F. Farnsworth Senior Fellow and the co-director of Stanford Center on China's Economy and Institutions in the Freeman Spogli Institute for International Studies and Stanford Institute for Economic Policy Research at Stanford University. He received his BS from the University of California, Berkeley, and his MS and PhD from Cornell University. Previously, Rozelle was a professor at the University of California, Davis and an assistant professor in Stanford’s Food Research Institute and department of economics. He currently is a member of several organizations, including the American Economics Association, the International Association for Agricultural Economists, and the Association for Asian Studies. Rozelle also serves on the editorial boards of Economic Development and Cultural Change, Agricultural Economics, the Australian Journal of Agricultural and Resource Economics, and the China Economic Review.
His research focuses almost exclusively on China and is concerned with: agricultural policy, including the supply, demand, and trade in agricultural projects; the emergence and evolution of markets and other economic institutions in the transition process and their implications for equity and efficiency; and the economics of poverty and inequality, with an emphasis on rural education, health and nutrition.
Rozelle's papers have been published in top academic journals, including Science, Nature, American Economic Review, and the Journal of Economic Literature. His book, Invisible China: How the Urban-Rural Divide Threatens China’s Rise, was published in 2020 by The University of Chicago Press. He is fluent in Chinese and has established a research program in which he has close working ties with several Chinese collaborators and policymakers. For the past 20 years, Rozelle has been the chair of the International Advisory Board of the Center for Chinese Agricultural Policy; a co-director of the University of California's Agricultural Issues Center; and a member of Stanford's Walter H. Shorenstein Asia-Pacific Research Center and the Center on Food Security and the Environment.
In recognition of his outstanding achievements, Rozelle has received numerous honors and awards, including the Friendship Award in 2008, the highest award given to a non-Chinese by the Premier; and the National Science and Technology Collaboration Award in 2009 for scientific achievement in collaborative research.