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.

Despite both requirements of and support for universal education up to grade 9, there are concerning reports that China is still suffering from high and maybe even rising dropout rates in some poor rural areas. Unfortunately, besides aggregated statistics from the Ministry of Education (which show almost universal compliance with the nine year compulsory education law), there is little independent, survey-based evidence on the nature of dropout in China. Between 2009 and 2010 we surveyed over 7,800 grade 7, 8, and 9 students from 46 randomly selected junior high schools in four counties in two provinces in North and Northwest China to measure the dropout rate. We also used the survey data to examine the factors that are correlated with dropping out, such as the opportunity cost of going to school, household poverty, and poor academic performance. According to the study’s findings, dropout rates between grade 7 and grade 8 reached 5.7 percent; dropout rates between grade 8 and grade 9 reached 9.0 percent. This means of the total number of students that matriculated into junior high school (those who were attending school during the first month of the first term of grade 7), 14.2 percent had left school by the first month of grade 9. Dropout rates were even higher for students that were older, from poorer families (and families in which the parents were not healthy), or were performing more poorly academically. We conclude that although the government’s policy of reducing tuition and fees for junior high students may be necessary, it is not sufficient to solve the dropout problem.

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.

The education of disadvantaged populations has been a long-standing challenge to the education system in both developed and developing countries. Although computer-assisted learning (CAL) has been considered one alternative to improve learning outcomes in a cost-effective way, the empirical evidence of its impacts on improving learning outcomes is mixed. This paper uses a cluster randomized field experiment in 57 schools (26 schools were part of the CAL program; 31 control schools were not) to explore the effects of the CAL program on student academic and non-cognitive outcomes for students in public schools in minority rural areas in China. Our results show that a remedial, game-based CAL program that focused on teaching Chinese (held out of regular school hours) improved the standardized Chinese scores of the students in the treatment schools by 0.14-0.19 standard deviations more than those in the control schools. Moreover, CAL also had significant spillover effects on student standardized math test scores. Still further, our results also show insignificant positive effects of CAL intervention on student non-academic outcomes of interest in studying and metacognition, and significant positive effect on student self-efficacy of Chinese studying. In general, low-performing students benefited more from the program. The CAL intervention also had mixed effects on the non-academic outcomes of students from different ethnic minority groups. 

China’s New Cooperative Medical Scheme, launched in 2003, was designed to protect rural households from the financial risk posed by health care costs and to increase the use of health care services. This article reports on findings from a longitudinal study of how the program affected the use of health care services, out-of-pocket spending on medical care, and the operations and financial viability of China’s township health centers, which constitute a middle tier of care in between village clinics and county hospitals. We found that between 2005 and 2008 the program provided some risk protection and increased the intensity of inpatient care at township health centers. Importantly, the program appears to have improved the centers’ financial status. At the same time, the program did not increase the overall number of patients served or the likelihood that a sick person would seek care at a township center. These findings serve as a benchmark of the program’s early impact. The results also suggest that the composition of health care use in China has changed, with people increasingly seeking outpatient care at village clinics and inpatient care at township health centers.

In the late 1990s and early 2000s, China’s Ministry of Education embarked on an ambitious program of elementary school mergers by shutting down small village schools and opening up larger centralized schools in towns and county seats. The goal of the program was to improve the teacher quality and building resources in an attempt to raise the human capital of students in poor rural areas, although it was recognized that students would lose the opportunity to learn in the setting of their own familiar villages. Because of the increased distances to the new centralized schools, the merger program also entailed building boarding facilities and encouraging or mandating that students live at school during the week away from their family. Given the magnitude of the program and the obvious mix of benefits and costs that such a program entails there has been surprisingly little effort to evaluate the impact of creating a new system that transfers students from school to school during their elementary school period of education and, in some cases, making students live in boarding facilities at school. In this paper, our overall goal is to examine the impact of the Rural Primary School Merger Program on the academic performance of students using a dataset from a survey that we designed to reflect transfer paths and boarding statuses of students. We use OLS and Propensity Score Matching approaches and demonstrate that there is a large “resource effect” (that is, an effect that appears to be associated with the better facilities and higher quality of teachers in town and county schools) that is associated with the transfer of students from less centralized schools (such as village schools) to more centralized schools. Boarding, however, is shown to have a negative impact on academic performance. However, students who transfer to county schools benefit from the transfer regardless of where they start and whether they board.

In this paper we present new evidence on the impact of health and nutrition information on anemia rates from three large-scale randomized controlled trials (RCTs) in rural China. Each RCT studies a different type of health education campaign designed in partnership with the Chinese government to reduce the prevalence of iron-deficiency anemia among rural primary school students. These campaigns include single and multiple face-to-face education sessions for parents at their children’s schools as well as dissemination of written health education materials. Across all three studies, we find little evidence of changes in blood hemoglobin concentration or anemia status. In contrast, in our two studies that also examined a multivitamin supplementation intervention, we find meaningful reductions in anemia.

Purpose – The purpose of this paper is to explore whether an in-service life teacher training program can improve boarding students’ health, behavior, and academic performance.

Design/methodology/approach – The authors conducted a cluster-randomized controlled trial to measure the effect of life teacher training on student health, behavior, and academic performance among 839 boarding students in ten central primary boarding schools in Shaanxi. And the authors also tried to identify why or why not life teacher training works. Both descriptive and multivariate analysis are used in this paper.

Findings – The authors find significant improvements in health and behavior. Specifically, compared to boarding students in control schools, 15 percent fewer students in treatment schools reported feeling cold while sleeping at night. The results also showed that student tardiness and misbehaviors after class declined significantly by 18 and 78 percent, respectively. However, the in-service life teacher training program had no measurable impact on boarding students’ BMI-for-age Z-score, number of misbehaviors in class, and academic performance. The analysis suggests that improved communication between life teachers and students might be one mechanism behind these results.

Originality/value – This is the first empirical work which explored how to improve the welfare of boarding students via their life teachers. Because of the sudden increase in boarding students in rural China, it is almost certain that school personnel lack experience in managing boarding students. As such, one promising approach to improving student outcomes might be in-service training for life teachers.

We estimate the effects of attending the first versus second-tier of higher education institutions on Chinese students’ at-college and expected post-college outcomes using various quasi-experimental methods such as regression discontinuity, genetic matching, and regression discontinuity controlling for covariates. Overall we find that just attending the first versus second-tier makes little difference in terms of students’ class ranking, net tuition, expected wages, or likelihood of applying for graduate school. The results do show, however, that just attending the first versus second tier makes it less likely that students will get their preferred major choice.