Stanford University

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Nutrition and Educational Performance in Rural China's Elementary Schools: Results of a Randomized Control Trial in Shaanxi Province

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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.

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Economic Development and Cultural Change
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Scott Rozelle

The Uses and Limitations of Forensic DNA Typing

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The tools of molecular biology have augmented forensic biological analyses and contributed to solving crimes, developing investigative leads, and exonerating the innocent. The methods are exquisitely sensitive and highly resolving. Success stories abound and are reported almost daily in the media. Indeed, forensic DNA typing is the gold standard of the forensic science disciplines. Although the methods and interpretations generally are reliable, there are some limitations that scientists, stakeholders, decision makers, and the public may not appreciate. This presentation will provide insight into the applications extolling their value and discussing the problems that need to be overcome or avoided.

About the speaker: Bruce Budowle, PhD, director of the UNT Health Science Center's Institute of Investigative Genetics and vice chair of the Department of Forensic and Investigative Genetics, has been named a Health Care Hero by Dallas Business Journal. He joined the Health Science Center in 2009, bringing renowned expertise in the areas of counterterrorism, primarily in identification of victims from mass disasters and microbial forensics.

Prior to joining the Health Science Center, Budowle spent 40 years as a senior scientist for the Federal Bureau of Investigation (FBI) in Washington, D.C. He was a principal advisor in efforts to identify victims from the World Trade Center attack in 2001 and helped establish a mitochondrial DNA sequencing program to enable high-throughput sequencing of human remains.

Budowle's commitment to helping families resolve missing persons cases led him to Fort Worth after a lifetime in the Virginia/Washington, D.C., area in order to collaborate with Health Science Center researchers and advance the knowledge and use of forensics and DNA to improve health and safety of the world's population. Budowle has also been instrumental in establishing the DNA-ProKids initiative to identify missing children on an international scale.

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Bruce Budowle Director Speaker University of North Texas Health Science Center Institute of Investigative Genetics
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China provides universal health insurance at a fraction of the cost

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China’s demographic landscape is rapidly changing, and the government has responded by launching ambitious social and health service reforms to meet the changing needs of the country’s 1.3 billion people. This week, officials approved a five-year plan to develop a comprehensive nationwide social security network.

Karen Eggleston, the Asia Health Policy Program (AHPP) director and a Stanford Health Policy fellow, discusses the success of China’s health care reforms—including its recently established universal health care system—and the long road still ahead.

Why is the overall health and wellbeing of China’s population important globally?

There are many reasons why the health of China’s citizens matters within a larger global context. On the most basic level, China represents almost 20 percent of humanity. But it is also a major player in the world economy and it depends on having a healthy workforce, especially now that its population is aging more. The government’s ability to meet the needs of its underserved citizens contributes to a more productive and stable China, and works towards closing the huge gaps we see in human wellbeing across the world.

China also potentially offers a model for other developing countries, such as India, that may want to figure out how to make universal health coverage work at a tenth of the income of most of the countries that have put it into place before.

What are some of the biggest changes in China’s health care system since 1949?

One of the most significant changes is that China has achieved very basic universal health insurance coverage in a relatively short period of time.  

Throughout the Mao period (1949–1978) there was a health care system linked to the centrally planned economy, which provided a basic level of coverage via government providers with a lot of regional variation. When economic reform came in 1980, large parts of the system—particularly financing for insurance—collapsed. The majority of China’s citizens were uninsured during the past few decades of very rapid social and economic development.

China’s overall population is changing quite dramatically, which means it has different health care needs, such as treating chronic disease and caring for an increasingly elderly population. The central government is trying to establish a system of accessible primary care—a concept that China’s barefoot doctors helped to pioneer but that fell into disarray—and health services that fit these new needs. 

How does China’s basic health care system work? Are there segments of the population still not receiving adequate coverage and care?

China has had a system where people can select their own doctors. Patients usually want to go to clinics attached to the highest-reputation hospitals, but of course, when you are not insured you almost always by default go to where you can afford the care. “It is difficult to see the doctor, and it is expensive” has been the lament of patients in China, so an explicit goal of the health care reforms has been to address this.

The term “universal coverage” has different definitions. China initially put in place a form of insurance that only covers 20 or 30 percent of medical costs for the previously uninsured population, especially in rural areas. Benefits have expanded, but remain limited. As with the previous system, disparities in coverage still exist across the population. China not only has a huge population with huge economic differences, but within that there is a large migrant worker population. It is a challenge to figure out how to cover these citizens and how to provide them with access to better care. The government is quite aware there are segments of the population not receiving equal coverage, and it continues to strive to resolve the issue.  

What are the greatest innovations in China’s health care system in recent years?

One of the most remarkable things China has achieved is really its new health insurance system. Even if the current coverage is not particularly generous it is nearly universal, and mechanisms are put in place each year to provide more generous coverage. China is also working on strengthening its primary care and population health services, infusing a huge sum of government money into these efforts. It is the only developing country of its per-capita income that has achieved such results so far.

Interestingly, a lot of people assume China achieved its universal coverage by mandate, while in fact the central government did so by subsidizing the cost for local governments and individuals. This reduces the burden, for example, on poorer rural governments and residents, and is one innovative way China is trying to eliminate the disparity in access to care.

Eggleston has recently published a working paper on China’s health care reforms since the Mao era on the AHPP website, as well as an article in the Milken Institute Review.

Gordon Liu, a Chinese government advisor on health care and the executive director of Peking University’s Health Economics and Management Institute, spoke at Stanford on May 29 on the future of China’s health care system.

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The Spillover Effect of National Health Insurance on Household Consumption Patterns in Taiwan

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One of the major aims of implementing a national health insurance program in Taiwan in 1995 was to provide financial risk protection to the country's 23 million citizens. Households may differ in how they allocate the resources freed up and available to them as a result of health insurance. This study presented by Jui-fen Rachel Lu aims to evaluate the impact of social insurance on household consumption patterns.

About the Speaker

Jui-fen Rachel Lu, ScD, is a professor in the Department of Health Care Management and dean of the College of Management at Chang Gung University in Taiwan, where she teaches comparative health systems, health economics, and health care financing. Her research focuses on equity issues in Taiwan's health care system; the impact of the National Health Insurance program on the health care market and household consumption patterns; and comparative health systems in the Asia-Pacific region. She earned her BS from National Taiwan University, and her MS and ScD from Harvard University.

Lu has served as a member of various government committees dealing with health care issues in Taiwan, and is the recipient of various awards. She is the author of Health Economics, and has published papers in journals including Health Affairs, Medical Care, and Journal of Health Economics. Her detailed CV can be found online.

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Jui-fen Rachel Lu Professor, Department of Health Care Management Speaker Chang Gung University, Taiwan
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Patterns of Elderly Life Expectancy in Three Chinese Cities: Hong Kong, Shanghai and Taipei

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Life expectancy at aged 65 is remarkably similar in the three Chinese cities of Hong Kong, Shanghai, and Taipei, even though the cities differ in levels of socioeconomic development, health systems, and other factors. Edward Jow-Ching Tu will discuss research that aims to understand this phenomenon. Despite unprecedented increases in life expectancy and attainment of similar current levels of life expectancy, the cities differ in the contributions of changes in major causes of death to the improvements in life expectancy among the elderly. Tu and colleagues have explored several possible determinants of these different patterns and trends in the three cities, including socioeconomic development, health service delivery systems, cause-of-death classification systems, and competing risks from cardiovascular disease and other diseases. Their analysis suggests that the effect of equity of health service delivery has become more important over time.

Edward Jow-Ching Tu is a senior lecturer of demography in the Division of Social Science at Hong Kong University of Science and Technology. His work is focused on the impact of fertility, mortality, and migration on socio-economic changes in East Asia countries with special emphasis on nations experiencing a transition from planned economy to market economy; on causes and impacts of mortality changes and health transition on aging societies; and on the causes of lowest-low fertility in many East Asia countries. He has several active research projects ongoing in China, Japan, Taiwan, Hong Kong, and Singapore. He holds graduate degress from West Virginia University, the University of Pennsylvania, and the University of Tennessee (Knoxville). Tu has worked extensively in Asia, and has served as an adjunct professor and taught in many universities in China, including Peking University, Peoples University, Nankai Univerity, and Fudan University. He had served as a senior research scientist at the New York State Health Department and as a research fellow (full professor) at the Institute for Social Sciences and Philosophy at Academia Sinica. Tu has also taught at the State University of New York in Albany.

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Edward Jow-Ching Tu Senior Lecturer of Demography at the Division of Social Science Speaker Hong Kong University of Science and Technology
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