Background: To study how misaligned supply-side incentives impede health programs in developing countries, we tested the impact of performance pay for anemia reduction in rural China. To the best of our knowledge, our study is the first to evaluate performance pay for actual health improvement.

Methods: We conducted a cluster randomised trial of information, subsidies, and incentives for school principals to reduce anemia among fourth and fifth grade students in 72 randomly-selected rural primary schools across northwest China. Our experiment included a control and three treatment arms: (1) an information arm in which principals received education about anemia; (2) a subsidy arm in which principals received information and unconditional subsidies; and (3) an incentive arm in which principals received information, subsidies, and financial incentives for reducing anemia among students. Students, parents, nursing teams, and survey enumerators were blind to arm assignment. Primary outcomes were student hemoglobin concentrations; secondary outcomes were behavioral responses to the interventions.

Findings: Mean student haemoglobin concentration rose by 1.5 g/L (95% CI –1.1 to 4.1) in information schools, 0.8 g/L (–1.8 to 3.3) in subsidy schools, and 2.4 g/L (0 to 4.9) in incentive schools compared with the control group. This increase in haemoglobin corresponded to a reduction in prevalence of anaemia (Hb <115 g/L) of 24% in incentive schools. Interactions with pre-existing incentives for principals to achieve good academic performance led to substantially larger gains in the information and incentive arms: when combined with incentives for good academic performance, associated effects on student haemoglobin concentration were 9.8 g/L (4.1 to 15.5) larger in information schools and 8.6 g/L (2.1 to 15.1) larger in incentive schools.

Interpretation: Financial incentives for health improvement were modestly effective. Understanding interactions with other motives and pre-existing incentives is critical.

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.

Objective. The overall goal of this paper is to test whether simple nutritional interventions lower rates of anemia and to assess whether this leads to improved educational performance among students in poor areas of rural China.

Approach: We report on the results of a randomized control trial (RCT) involving over 3600 fourth grade students, mostly aged 9 to 12, from 66 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 three groups: two different types of treatment/intervention schools; a non-intervention, control group. The two interventions were designed to improve hemoglobin (Hb) levels, which is a measure of iron deficiency. One intervention provided a daily multivitamin with mineral supplements, including 5 milligrams of iron, for 5 months. The other informed the parents of their child’s anemia status and suggested several courses of action (henceforth, the information treatment).

Findings: Some 38.3 percent of the students had Hb levels of below 120 g/L, the World Health Organization’s cutoff for anemia for children 9 to 12 years old. In the schools that received the multivitamins with mineral supplements, Hb levels rose by more than 2 g/L (about 0.2 standard deviations). The standardized math test scores of the students in the schools that received the multivitamin with mineral supplements also improved significantly. In schools that received the information treatment, only students that lived at home (and not the students that lived in boarding schools and took most of their meals at schools) registered positive improvements in their Hb levels. The reductions in anemia rates and improvements in test scores were greater for students that were anemic at the beginning of the study period. Overall, these results should encourage China’s Ministry of Education (MOE) to begin to widen its view of education (beyond teachers, facilities and curriculum) and provide better nutrition and health care for students.