Unlike performance incentives for private sector managers, little is known about performance incentives for managers in public sector bureaucracies. Through a randomized trial in rural China, we study performance incentives rewarding school administrators for reducing student anemia -- as well as complementarity between incentives and orthogonally assigned discretionary resources. Large (but not small) incentives and unrestricted grants both reduced anemia, but incentives were more cost-effective. Although unrestricted grants and small incentives do not interact, grants fully crowd-out the effect of larger incentives. Our findings suggest that performance incentives can be effective in bureaucratic environments, but they are not complementary to discretionary resources. 

Poor rural areas in China exhibit the country’s highest rates of child mortality, often stemming from preventable health conditions such as diarrhea and respiratory infection. In this study, we investigate the association between breastfeeding and disease among children aged 6–24 months in poor rural counties in China. To do this, we conducted a longitudinal, quantitative analysis of socioeconomic demographics, health outcomes, and breastfeeding practices for 1802 child–caregiver dyads across 11 nationally designated poverty counties in southern Shaanxi Province in 2013–2014. We found low rates of continued breastfeeding that decreased as children developed: from 58.2% at 6–12 months, to 21.6% at 12–18 months, and finally to 5.2% at 18–24 months. These suboptimal rates are lower than all but one other country in the Asia-Pacific region. We further found that only 18.3% of children 6–12 months old met the World Health Organization (WHO)-recommended threshold for minimum dietary diversity, defined as consuming four or more of seven specific food groups. Breastfeeding was strongly associated with lower rates of both diarrhea and cough in bivariate and multivariate analyses. As the first analysis to use longitudinal data to examine the relationship between continued breastfeeding and child illness in China, our study confirms the need for programmatic interventions that promote continued breastfeeding in order to improve toddler health in the region.

It is commonly believed that reading challenges should be addressed early to reduce the likelihood that developmental delays will impact students over the long term. However, students in developing countries often have limited access to reading resources. In this study, the authors used a randomized controlled trial of 11,083 fourth‐ and fifth‐grade students in 120 primary schools in rural China to examine the causal effect of an in‐class library program on student reading outcomes and academic achievement in schools with poor reading resources over an eight‐month period. An in‐class library was installed in each of the selected classes in the 40 treatment schools. The authors found that the program significantly improved student affinity toward reading and student reading habits, and in these regards, it narrowed the gap between male and female students, between low‐ and high‐performing students, and between left‐behind children and children living with parents. However, the authors found no overall effect of the program on reading and academic achievement and a negative effect on student confidence in reading. There was also no effect on student, teacher, and primary caregiver perceptions toward the effect of independent reading on academic achievement, nor any effect on whether teachers and primary caregivers provided reading instructions to students. The authors propose three possible explanations for these findings: a lack of reading instruction from teachers and caregivers, a lack of reading materials specifically tailored to local needs and interests, and the relatively short duration of the intervention.

Large and increasing numbers of rural-to-urban migrants provided new challenges for tuberculosis control in large cities in China and increased the need for high quality tuberculosis care delivered by clinics in urban migrant communities. Based on a household survey in migrant communities, we selected and separated clinics into those that mainly serve migrants and those that mainly serve local residents. Using standardized patients, this study provided an objective comparison of the quality of tuberculosis care delivered by both types of clinics and examined factors related to quality care. Only 27% (95% confidence interval (CI) 14–46) of cases were correctly managed in migrant clinics, which is significantly worse than it in local clinics (50%, 95% CI 28–72). Clinicians with a base salary were 41 percentage points more likely to demonstrate better case management. Furthermore, clinicians with upper secondary or higher education level charged 20 RMB lower out of pocket fees than less-educated clinicians. In conclusion, the quality of tuberculosis care accessed by migrants was very poor and policies to improve the quality should be prioritized in current health reforms. Providing a base salary was a possible way to improve quality of care and increasing the education attainment of urban community clinicians might reduce the heavy barrier of medical expenses for migrants

The goal of this paper is to describe and analyze the relationship between ability tracking and student social trust, in the context of low-income students in developing countries. Drawing on the results from a longitudinal study among 1,436 low-income students across 132 schools in rural China, we found a significant lack of interpersonal trust and confidence in public institutions among poor rural young adults. We also found that slow-tracked students have a significantly lower level of social trust, comprised of interpersonal trust and confidence in public institutions, relative to their fast-tracked peers. This disparity might further widen the gap between relatively privileged students who stay in school and less privileged students who drop out of school. These results suggest that making high school accessible to more students may improve social trust among rural low-income young adults.

Education of poor and disadvantaged populations has been a long-standing challenge for education systems in both developed and developing countries. In China, millions of students in rural areas and migrant communities lag far behind their urban counterparts in terms of academic achievement. When they fall behind, they often have no way to catch up. Many of their parents have neither the skills nor the money to provide remedial tutoring; rural teachers often do not have time to give students the individual attention they need. Given this, there is growing interest by both educators and policymakers in helping underperforming students catch up using computer assisted learning (CAL). While CAL interventions have been shown to be effective internationally and elsewhere in China, traditional software-based CAL programs are difficult and costly to implement. An online version of CAL (OCAL), however, may be able to bypass many of offline CAL’s implementation problems and enhance the remedial tutoring experience. Unfortunately, there is little empirical evidence on whether OCAL programs can be effective in improving the quality of rural primary school education in developing countries. The objective of this paper is to examine the impact of an OCAL intervention on the academic and non-academic performance of students and to explore the mechanism behind OCAL’s impact. Importantly, we also aim to assess the cost effectiveness of the new OCAL program versus traditional CAL interventions. To achieve these objectives, we carried out a randomized controlled trial (RCT) involving over 1650 fifth grade students in 44 schools in rural areas and migrant communities across China. Students in the 22 treatment schools attended two 40- minute OCAL sessions during their computer class each week for one semester; the students in the other 22 schools were in the control group and did not receive any intervention. According to our findings, OCAL improved overall English scores of students in the treatment group relative to the control group by 0.56 standard deviations. This impact is large when compared with offline CAL programs. We found that OCAL also led to a positive change in the attitudes of students towards English learning and towards student aspirations for their future education level. We found three possible explanations for OCAL’s impact. After rejecting the possibility of the Hawthorne Effect or self-efficacy-induced changes, we believe interest-oriented stimulation is the main source of improvement among students. The chance for comparison and competition with peers, as well as customized remedial question banks tailored to each student’s individual needs, likely contributed to the measured increases in academic performance among students in our sample. Cost-effectiveness analysis showed that the OCAL program is more cost-effective than traditional offline CAL, a comparison which is significant for policymakers as it indicates high potential for OCAL program expansion. 

In this paper, we attempt to evaluate the effectiveness of reading programs at improving the reading skills and academic achievement of primary school students in rural China. Using survey data on 4108 students, we find that students exhibited low levels of reading achievement, independent reading quantity, and reading confidence in the absence of any treatment. However, our results also suggest that properly designed treatments may improve the reading and academic outcomes of students. Specifically, we found that increased access to independent reading materials coupled with effective teacher training led to significant improvements in student reading skills, math test scores, and Chinese test scores. We believe that these improvements are due to changes in reading instruction and the attitudes of teachers toward reading. These findings indicate that encouraging higher reading quantity and providing high-quality reading instruction are important components for programs that seek to improve student outcomes in developing country settings.