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.

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.

The main goal of this paper is to analyze the factors (access, attendance and quality of preschools) that may be affecting the educational readiness of China’s rural children before they enter the formal school system. Using data from a survey of 80 preschools and 500 households in 6 counties in 3 provinces of China, this paper documents the nature of early childhood education (ECE) services and the educational readiness of children aged 4-5 in rural China. We present evidence that ECE services are seriously deficient. Households in many areas of rural China do not have convenient access to preschool facilities. Preschools have poor facilities, inadequate health services, and little concern for the nutrition of their students. Most teachers have little formal training. In part due (perhaps) to the poor quality and low participation in preschool, in this paper we will show that China's rural children score much lower on standardized educational readiness tests. In fact, according to our findings, more than one half of the rural children in our sample are “not ready” for continuing into the next level of formal education. Our analysis implies that it is necessary to improve the facilities and quality of teachers and to increase the probability that children will be sent to ECE institution.

Opportunities to go to college and earn a degree have risen dramatically in China. Government investment into the college systems has skyrocketed and the size of universities has increased by more than five times over the past decade. With the rise in the opportunity to go to college, several questions naturally arise: Are the rural poor—perhaps those that would most benefit individually as well as provide spillovers to their home communities—being systematically excluded? If they are, what are the barriers that are keeping them from having access to higher education?

The overall goal of this paper is to answer these questions. To do so, we combine two sets of our own primary survey data. One survey covers a group of randomly selected high school students from the poor parts of Shaanxi province, one of China’s poorest provinces. The other survey is a census of all freshman entering into four universities in three poor provinces. With these data we seek to identify if China’s rural poor are being systematically excluded from the university system, and if so, why.

In the first part of the results section of the paper, we show that the participation rate of the poor accessing to college education is substantially lower than the students from nonpoor families. Clearly, there are barriers that are keeping the rural poor out. In the rest of the paper, we examine two general categories of barriers. First, according to our data from Shaanxi province, it does not appear that any real barriers appear at the period of time between the final year of high school and the first year of college. We find no empirical evidence that the College Entrance Exam (CEE) is biased against the poor; the exam scores of poor students are virtually the same as the exam scores of nonpoor students, holding all other factors constant. There is some evidence that the nature of the CEE process—particularly that the timing of when students find out about financial aid—distorts the decisions of poorer students regarding what college to attend and what major to pursue. At the same time, however, we observe that the admission rates between poor and nonpoor are statistically the same when poor students are admitted to university. Contrary to commonly held beliefs, we find that virtually every student who passes the entrance exam (poor and nonpoor alike) is able to find a way to pay the fees and tuition charges that are demanded upon matriculation and is able to enter college, despite the high costs.

Therefore, the paper concludes that if the real barriers are not at the time of admissions to college, there must be a second, remaining set of systematic barriers that prevent poor children from ever making it to the point where they take the CEE. In fact, a close reading of the literature and some of our own data demonstrate that the rural education system—in general—is putting rural children at a severe disadvantage at almost every point of the educational process (low rates of enrollment into early childhood education; low quality elementary schools; poor nutrition and low quality boarding facilities; high levels of high school tuition; a migrant schooling system that is outside of the public education system).

The paper concludes that the real barriers keeping the rural poor from pursuing a college education are being erected early in their educational experience—as early as preschool and elementary school—and are present throughout the entire schooling system.

The main goal of this paper is to document the nature of boarding schools and empirically analyze the difference of nutrition intake and malnutrition status between boarding and non-boarding students in western rural China. By using two data sets about boarding schools and boarding students in Shaanxi Province, a representative province in western rural China, this paper finds that dormitory and student canteen facilities in boarding schools are under-equipped and services are poor quality and far below that needed for student development. Poor services in boarding schools and inadequate nutrition intake may be an important cause of low student height-for-age Z-scores (HAZ), as students eating at school have a much lower HAZ on average than that of non-boarding students. Furthermore, girls and students with more siblings have relatively lower HAZ, while the higher the number of parents a student has and the more educated they are exert a positive influence on child nutritional status in terms of HAZ. Finally, our analysis implies that the effective way to decrease the inequality of health, malnutrition and human capital between urban and rural in the long run is to improve the facilities and services of boarding schools in rural China.

The overall goal of the paper is to understand the progress of the design and implementation of China’s New Cooperative Medical System (NCMS) program between 2004 (the second year of the program) and 2007. In the paper we seek to assess some of the strengths and weaknesses of the program using a panel of national- representative, household survey data that were collected in 2005 and early 2008. According to our data, we confirm the recent reports by the Ministry of Health that there have been substantial improvements to the NCMS program in terms of coverage and participation. We also show that rural individuals also perceive an improvement in service by 2007. While the progress of the NCMS program is clear, there are still weaknesses. Most importantly, the program clearly does not meet one of its key goals of providing insurance against catastrophic illnesses. On average, individuals that required inpatient treatment in 2007 were reimbursed for 15% of their expenditures. Although this is higher than in 2004, on average, as the severity of the illness (in terms of expenditures on health care) rose, the real reimbursement rate (reimbursement amount/total expenditure on medical care) fell. The real reimbursement rate for illnesses that required expenditures between 4000 and 10000 yuan (over 10000 yuan) was only 11% (8%). Our analysis shows that one of the limiting factors is constrained funding.