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This paper examines the effects of China’s New Cooperative Medical Scheme (NCMS) on medical expenditure. Utilizing the quasi-random rollout of the NCMS for a difference-in-difference analysis, we find that the NCMS increased medical expenditure by 12.3%. Most significantly, the good-health group witnessed a 22.1% rise in medical expenditure, and the high-income group saw a rise of 20.6%. The effects, however, were not significant among the poor-health or low-income groups. The findings are suggestive of the need for more help for the very poor and less healthy.
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Healthcare
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Scott Rozelle
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Educational tracks create differential expectations of student ability, raising concerns that the negative stereotypes associated with lower tracks might threaten student performance. The authors test this concern by drawing on a field experiment enrolling 11,624 Chinese vocational high school students, half of whom were randomly primed about their tracks before taking technical skill and math exams. As in almost all countries, Chinese students are sorted between vocational and academic tracks, and vocational students are stereotyped as having poor academic abilities. Priming had no effect on technical skills and, contrary to hypotheses, modestly improved math performance. In exploring multiple interpretations, the authors highlight how vocational tracking may crystallize stereotypes but simultaneously diminishes stereotype threat by removing academic performance as a central measure of merit. Taken together, the study implies that reminding students about their vocational or academic identities is unlikely to further contribute to achievement gaps by educational track.

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Socius
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Prashant Loyalka
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Previous literature suggests subpar teaching is a primary reason why rural Chinese students lag behind academically. We initiate an investigation into the potential of educational technology (EdTech) to increase teaching quality in rural China. First, we discuss why conventional approaches of improving teaching in remote schools are infeasible in China’s context, referring to past research. We then explore the capacity of technology-assisted instruction to improve academic performance by examining previous empirical analyses. Third, we show that China is not limited by the resource constraints of other developing countries due to substantial policy support and a thriving EdTech industry. Finally, we identify potential implementation-related challenges based on the results of a preliminary qualitative survey of pilots of EdTech interventions. With this paper, we lay the foundation for a long-term research investigation into whether EdTech can narrow China’s education gap.

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Matthew Boswell
Prashant Loyalka
Scott Rozelle
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Inadequate care during early childhood can lead to long-term deficits in skill development. Parenting programs are promising tools for improving parenting practices and opportunities for healthy development. We implemented a non-masked cluster-randomized controlled trial in rural China in order to assess the effectiveness of an integrated home-visitation program that includes both psychosocial stimulation and health promotion at fostering development and health outcomes of infants and toddlers in rural China. All 6-18 month-old children of two rural townships and their main caregiver were enrolled. Villages were stratified by township and randomly assigned to intervention or control. Specifically, in September 2015 we assigned 43 clusters to treatment (21 villages, 222 caregiver-child dyads) or control (22 villages, 227 caregiver-child dyads). In the intervention group, community health workers delivered education and training on how to provide young children with psychosocial stimulation and health care (henceforth psychosocial stimulation and health promotion) during bi-weekly home visits over the period of one year. The control group received no home visits. Primary outcomes include measures of child development (i.e. the Bayley Scales of Infant and Toddler Development, third edition—or Bayley-III) and health (i.e. measures of morbidity, nutrition, and growth). Secondary outcomes are measures of parenting practices. Intention-to-treat (ITT) effects show that the intervention led to an improvement of 0·24 standard deviations (SD) [95% CI 0·04 SD-0·44 SD] in cognitive development and to a reduction of 8·1 [95% CI 3·8–12·4] percentage points in the risk of diarrheal illness. In addition, we find positive effects on parenting practices mirroring these results. We conclude that an integrated psychosocial stimulation and health promotion program improves development and health outcomes of infants and toddlers (6–30 month-old children) in rural China. Because of low incremental costs of adding program components (that is, adding health promotion to psychosocial stimulation programs), integrated programs may be cost-effective.

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Social Science & Medicine
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Scott Rozelle
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Background: Various types of near work have been suggested to promote the incidence and progression of myopia, while outdoor activity appears to prevent or retard myopia. However, there is a lack of consensus on how to interpret these results and translate them into effective intervention strategies. This study examined the association between visual acuity and time allocated to various activities among school-going children.
Methods: Population-based survey of 19,934 students in grade 4 and 5 from 252 randomly selected rural primary schools in Northwest China in September 2012. This survey measured visual acuity and collected self-reported data on time spent outdoors and time spent doing various types of near activities.
Results:  Prolonged (>60 minutes/day) computer usage (-0.025 LogMAR units, P = .011) and smartphone usage (-0.041 LogMAR units, P = .001) were significantly associated with greater refractive error, while television viewing and after-school study were not. For time spent outdoors, only time around midday was significantly associated with better uncorrected visual acuity. Compared to children who reported no midday time outdoors, those who spent time outdoors at midday for 31–60 minutes or more than 60 minutes had better uncorrected visual acuity by 0.016 LogMAR units (P = .014) and 0.016 units (P = .042), respectively.
Conclusions: Use of smart phones and computers were associated with declines in children’s vision, while television viewing was not. Statistically significant associations between outdoor time at midday and reduced myopia may support the hypothesis that light intensity plays a role in the protective effects of outdoor time.

 

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PLoS ONe
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Huan Wang
Matthew Boswell
Scott Rozelle
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Anemia is a serious nutritional deficiency among infants and toddlers in rural China. However, it is unclear how the anemia status changes among China’s rural children as they age. This study investigates the prevalence of anemia as children grow from infancy to preschool-age, as well as the dynamic anemia status of children over time. We conducted longitudinal surveys of 1170 children in the Qinba Mountain Area of China in 2013, 2015 and 2017. The results show that 51% of children were anemic in infancy (6–12 months), 24% in toddlerhood (22–30 months) and 19% at preschool-age (49–65 months). An even larger share of children (67%) su ered from anemia at some point over the course of study. The data also show that although only 4% of children were persistently anemic from infancy to preschool-age, 8% of children saw their anemia status deteriorate. We further found that children may be at greater risk for developing anemia, or for having persistent anemia, during the period between toddlerhood and preschool-age. Combined with the finding that children with improving anemia status showed higher cognition than persistently anemic children, there is an urgent need for e ective nutritional interventions to combat anemia as children grow, especially between toddlerhood and preschool age.
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International Journal of Environmental Research and Public Health
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Scott Rozelle
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China's rapid development has led to an unprecedented increase in migration rates as an evergrowing number of rural residents migrate to urban areas to seek better job opportunities an help alleviate family poverty. Economic pressures and structural restrictions force many of these migrant workers to leave their children behind in their rural homes, which has led to the emergence and expansion of a new subpopulation in China: left-behind children (LBCs). This study examines the impacts of parental migration on the educational outcomes (specifically math achievement) and mental health (specifically anxiety) of LBCs using data covering 7495 children in a prefecture of Shaanxi Province (from three surveys conducted between 2012 and 2014). We distinguish between “both parents migrating,” “one parent migrating,” “only a father migrating,” and “only a mother migrating.” We also explore the impacts on male versus female LBCs. We find no significant impact of parental migration on the math achievement of LBCs. In terms of mental health, however, our results indicate that left-behind girls were negatively affected by one parent migrating, especially if the migrating parent was the father. The findings suggest that it may not be necessary for policy makers to design special programs to improve educational outcomes of LBCs in general. However, local committees, schools, and parents should pay particular attention to left-behind girls living with only one parent, as they may be more vulnerable to mental health problems than their peers.
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China Economic Review
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Prashant Loyalka
Scott Rozelle
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In recent years, researchers have begun to focus attention on trying to identify systematic factors that cause interventions to have different impacts in different contexts. In this paper, we seek to understand whether the age of principals at schools implementing nutrition-based interventions has an impact on program outcomes. To explore the relative effectiveness of younger and older school principals, we use data from five large-scale, nutrition-related randomized controlled trials (RCTs) involving 12,595 primary school students in 336 schools in rural China. Our results, using two age cut-offs for distinguishing young principals from old ones, indicate that improvements in the health and nutrition outcomes of students were significantly higher in schools with younger principals than in schools run by older principals (when using a cutoff of 40 years old). When using a cut-off of 45 years old, the point estimates of the impacts similarly suggest that young principals are more effective, although the results are not significantly significant. The results are similar when we look at the impact of disaggregated interventions in schools managed by young and old principals. The findings are clear that the interventions implemented by older principals are not more effective than those implemented by younger principals.

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Journal of Development Effectiveness
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Scott Rozelle
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Choosing a valid and feasible method to measure child developmental outcomes is key to addressing developmental delays, which have been shown to be associated with high levels of unemployment, participation in crime, and teen pregnancies. However, measuring early childhood development (ECD) with multi-dimensional diagnostic tests such as the Bayley Scales of Infant and Toddler Development III (Bayley-III) can be time-consuming and expensive; therefore, parental screening tools such as the Ages and Stages Questionnaire (ASQ-3) are frequently an alternative measure of early childhood development in largescale research. The ASQ is also becoming more frequently used as the first step to identify children at risk for developmental delays before conducting a diagnostic test to confirm. However, the effectiveness of the ASQ-3 is uncertain. In this study, we evaluate the accuracy of the ASQ-3 as a screening measure for children at risk of developmental delay in rural China by age group. To do so, we administered the Bayley-III, widely considered to be the “gold standard” of ECD diagnostic tests, to a sample of 1,831 five to twenty-four monthold children and also administered the ASQ-3 to their caregivers. We then compared the outcomes of the ASQ-3 test to those of the Bayley-III. We find that the ASQ-3 was significantly though weakly correlated with the Bayley-III and that the strength of this correlation increased with child age and was stronger when the mother was the primary caregiver (as compared to the grandmother). We also find that the sensitivity and specificity of ASQ-3 ranged widely. The overall findings suggest that the ASQ-3 may not be a very accurate screening tool for identifying developmentally delayed children, especially for children under 13 months of age or children whose primary caregiver is not the mother.

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PLoS ONE
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Alexis Medina
Scott Rozelle
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In China, low levels of early childhood development (ECD) in rural areas may inhibit economic development as the nation attempts to transition from a middle-income manufacturing-based economy to a high-income innovation economy. This paper surveys the recent literature on ECD among children ages 0-3 years in rural China, including rates of developmental delays, causes of delays, and implications for the future of China’s economy. Recent studies have found high rates of developmental delays among young children in rural China and point to poor nutrition and psychosocial stimulation as the primary causes. This review highlights the need for large-scale ECD interventions in rural China to raise human capital and support future economic growth.

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The Asia-Pacific Journal
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Scott Rozelle
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