Paying-for-performance and cost effectiveness of strategies to combat anaemia in China

INTERVENTION: Information only: To some randomly‐assigned schools we provided three types of information to school principals: 1. The share of enrolled students who are anaemic 2. Descriptions of efficacious methods for reducing anaemia (including vitamin supplementation, lunch fortification, and other dietary changes as well as the possible role of educating parents about anaemia) 3. Details about anaemia's relationship to school attendance, educational performance, and cognitive development as reported in peer‐reviewed academic studies Information and earmarked operating budget subsidy (hereafter termed "Subsidy" for simplicity): Because purchasing inputs to reduce anaemia may be difficult given current operating budgets (which have little discretionary funds available), we randomly assigned some schools to receive earmarked operating budget subsidies. The subsidy schools were given 1.5 RMB per student per day, an amount that was enough to buy two to three ounces of red meat if the entire amount was spent on red meat. These subsidies are only allowed to be used for nutrition‐related expenses. However, it is always possible that other components of a school budget could be re‐allocated, effectively resulting in subsidies being used for other more highly prioritised purposes (if a school's own nutrition spending fell in response to the subsidy); we investigate this possibility directly. In addition, we provide exactly the same information to principals as in Information only schools. Information and earmarked operating budget subsidy and anaemia reduction incentive (hereafter termed "Incentive"): To test the effectiveness of direct rewards for health improvement, we randomly assigned a third group of school principals to receive performance payments for reductions in anaemia among their student populations. Given the governance structure of Chinese primary schools, school principals make executive decisions about school operations (National People's Congress 1995). In CONDITION: Iron deficiency anaemia ; Haematological Disorders ; Iron deficiency anaemia PRIMARY OUTCOME: Haemoglobin concentrations, obtained by finger prick testing using HemoCue AB point‐of‐care diagnostics, measured during the evaluation survey, six months after the start of the treatment SECONDARY OUTCOME: Measured during the evaluation survey, six months after the start of the treatment:; 1. Differential approaches of principals to reduce anaemia; 2. Changes over time in the composition of meals at home (meat, tofu, and fruit); 3. Changes in school budgetary allocations in both the Subsidy, Incentive and Information only groups relative to the Control group INCLUSION CRITERIA: All fourth and fifth grade students (both male and female students ages 8 ‐ 11 years) in 57 randomly selected rural primary schools in ten nationally designated poor counties in China's Ningxia and Qinghai provinces.