Hongmei Yi

New Evidence on the Impact of China's New Rural Cooperative Medical Scheme and its Implications for Rural Primary Healthcare: Multivariate Difference-in-Difference Analysis

Objectives To determine whether China’s New Rural Cooperative Medical Scheme (NCMS), which aims to provide health insurance to 800 million rural citizens and to correct distortions in rural primary care, and the individual policy attributes have affected the operation and use of village health clinics. Design We performed a difference-in-difference analysis using multivariate linear regressions, controlling for clinic and individual attributes as well as village and year effects. Setting 100 villages within 25 rural counties across five Chinese provinces in 2004 and 2007. Participants 160 village primary care clinics and 8339 individuals. Main outcome measures Clinic outcomes were log average weekly patient flow, log average monthly gross income, log total annual net income, and the proportion of monthly gross income from medicine sales. Individual outcomes were probability of seeking medical care, log annual “out of pocket” health expenditure, and two measures of exposure to financial risk (probability of incurring out of pocket health expenditure above the 90th percentile of spending among the uninsured and probability of financing medical care by borrowing or selling assets). Results For village clinics, we found that NCMS was associated with a 26% increase in weekly patient flow and a 29% increase in monthly gross income, but no change in annual net revenue or the proportion of monthly income from drug revenue. For individuals, participation in NCMS was associated with a 5% increase in village clinic use, but no change in overall medical care use. Also, out of pocket medical spending fell by 19% and the two measures of exposure to financial risk declined by 24-63%. These changes occurred across heterogeneous county programmes, even in those with minimal benefit packages. Conclusions NCMS provides some financial risk protection for individuals in rural China and has partly corrected distortions in Chinese rural healthcare (reducing the oversupply of specialty services and prescription drugs). However, the scheme may have also shifted uncompensated new responsibilities to village clinics. Given renewed interest among Chinese policy makers in strengthening primary care, the effect of NCMS deserves greater attention.

Health insurance and catastrophic illness: a report on the New Cooperative Medical System in rural China.

The overall goal of the paper is to understand the progress of the design and implementation of Chinas 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 10,000 yuan (over 10,000 yuan) was only 11% (8%). Our analysis shows that one of the limiting factors is constrained funding.

Effect of providing free glasses on children’s educational outcomes in China: cluster randomized controlled trial

Objective To assess the effect of provision of free glasses on academic performance in rural Chinese children with myopia. Design Cluster randomized, investigator masked, controlled trial. Setting 252 primary schools in two prefectures in western China, 2012-13. Participants 3177 of 19 934 children in fourth and fifth grades (mean age 10.5 years) with visual acuity <6/12 in either eye without glasses correctable to >6/12 with glasses. 3052 (96.0%) completed the study. Interventions Children were randomized by school (84 schools per arm) to one of three interventions at the beginning of the school year: prescription for glasses only (control group), vouchers for free glasses at a local facility, or free glasses provided in class. Main outcome measures Spectacle wear at endline examination and end of year score on a specially designed mathematics test, adjusted for baseline score and expressed in standard deviations. Results Among 3177 eligible children, 1036 (32.6%) were randomized to control, 988 (31.1%) to vouchers, and 1153 (36.3%) to free glasses in class. All eligible children would benefit from glasses, but only 15% wore them at baseline. At closeout glasses wear was 41% (observed) and 68% (self reported) in the free glasses group, and 26% (observed) and 37% (self reported) in the controls. Effect on test score was 0.11 SD (95% confidence interval 0.01 to 0.21) when the free glasses group was compared with the control group. The adjusted effect of providing free glasses (0.10, 0.002 to 0.19) was greater than parental education (0.03, −0.04 to 0.09) or family wealth (0.01, −0.06 to 0.08). This difference between groups was significant, but was smaller than the prespecified 0.20 SD difference that the study was powered to detect. Conclusions The provision of free glasses to Chinese children with myopia improves children’s performance on mathematics testing to a statistically significant degree, despite imperfect compliance, although the observed difference between groups was smaller than the study was originally designed to detect. Myopia is common and rarely corrected in this setting. Trial Registration Current Controlled Trials ISRCTN03252665.

School Dropouts and Conditional Cash Transfers: Evidence from a Randomised Controlled Trial in Rural China's Junior High Schools

Recent anecdotal reports suggest that dropout rates may be higher and actually increasing over time in poor rural areas. There are many reasons not to be surprised that there is a dropout problem, given the fact that China has a high level of poverty among the rural population, a highly competitive education system and rapidly increasing wages for unskilled workers. The overall goal of this study is to examine if there is a dropout problem in rural China and to explore the effectiveness that a Conditional Cash Transfer (CCT) program could have on dropouts (and mechanism by which the CCT might affect drop outs). To meet this objective, we conducted a randomized controlled trial (RCT) of a CCT using a sample of 300 junior high school students in a nationally-designated poor county in Northwest China. Using our data, we found that the annual dropout rate in the study county was high, about 7.0%. We find, however, that a CCT program reduces drop outs by 60%; the dropout rate is 13.3% in the control group and 5.3 % in the treatment group. The program is most effective in the case of girls, younger students and the poorest performing students.

China’s Left-Behind Children: Impact Of Parental Migration On Health, Nutrition, And Educational Outcomes

Chinas rapid development and urbanization have induced large numbers of rural residents to migrate from their homes to urban areas in search of better job opportunities. Parents typically leave their children behind with a caregiver, creating a new, potentially vulnerable subpopulation of left-behind children in rural areas. A growing number of policies and nongovernmental organization efforts target these children. The primary objective of this study was to examine whether left-behind children are really the most vulnerable and in need of special programs. Pulling data from a comprehensive data set covering 141,000 children in ten provinces (from twenty-seven surveys conducted between 2009 and 2013), we analyzed nine indicators of health, nutrition, and education. We found that for all nine indicators, left-behind children performed as well as or better than children living with both parents. However, both groups of children performed poorly on most of these indicators. Based on these findings, we recommend that special programs designed to improve health, nutrition, and education among left-behind children be expanded to cover all children in rural China.

Can Information and Counseling Help Students from Poor Rural Areas Go to High School? Evidence from China

Recent studies have shown that only about two-thirds of the students from poor, rural areas in China finish junior high school and enter high school. One factor that may be behind the low rates of high school attendance is that students may be misinformed about the returns to schooling or lack career planning skills. We therefore conduct a cluster-randomized controlled trial (RCT) using a sample of 131 junior high schools and more than 12,000 students to test the effects of providing information on returns or career planning skills on student dropout, academic achievement and plans to go to high school. Contrary to previous studies, we find that information does not have significant effects on student outcomes. Unlike information, counseling does have an effect. However, the effect is somewhat surprising. Our findings suggest that counseling increases dropouts and seems to lower academic achievement. In our analysis of the causal chain, we conclude that financial constraints and the poor quality of education in junior high schools in poor, rural areas (the venue of the study) may be contributing to the absence of positive impacts on student outcomes from information and counseling. The negative effects of counseling on dropout may also be due to the high and growing wages for unskilled labor (high opportunity costs) in China’s transitioning economy. It is possible that when our counseling curriculum informed the students about the reality of how difficult were the requirements for entering academic high school, it may have induced them to revise their benefit-cost calculations and come to the realization that they are better off dropping out and/or working less hard in school.

Transfer Paths and Academic Performance: The Primary School Merger Program in China

A B S T R A C T In the late 1990s and early 2000s, China’s Ministry of Education embarked on an ambitious program of primary school mergers by shutting down small village schools and opening up larger centralized schools in towns and county seats. The goal of the program was to improve the teacher and building resources in an attempt to raise the human capital of students in poor rural areas, although it was recognized that students would lose the opportunity to learn in the settings of their own familiar villages. Because of the increased distances to the new centralized schools, the merger program also entailed building boarding facilities and encouraging or mandating that students live at school during the week away from their family. Given the magnitude of the program and the obvious mix of benefits and costs that such a program entails there has been surprisingly little effort to evaluate the impact of creating a new system that transfers students from school to school during their primary school period of education and, in some cases, making student live in boarding facilities at school. In this paper, our overall goal is to examine the impact of the Rural Primary School Merger Program on academic performance of students using a dataset from a survey that we designed to reflect transfer paths and boarding statuses of students. We use OLS and Propensity Score Matching approaches and demonstrate that there is a large ‘‘resource effect’’ (that is, an effect that appears to be associated with the better facilities and higher quality of teachers in the town and county schools) that appears to be associated with the transfers of students from less centralized schools (such as village schools) to more centralized schools. Boarding, however, is shown to have negative impacts on academic performance. However, students who transfer to county school benefit from the transfer no matter where they start and whether they board or not.

Soil-Transmitted Helminths in Southwestern China: A Cross-Sectional Study of Links to Cognitive Ability, Nutrition, and School Performance among Children

Background Empirical evidence suggests that the prevalence of soil-transmitted helminth (STH) infections in remote and poor rural areas is still high among children, the most vulnerable to infection. There is concern that STH infections may detrimentally affect children’s healthy development, including their cognitive ability, nutritional status, and school performance. Medical studies have not yet identified the exact nature of the impact STH infections have on children. The objective of this study is to examine the relationship between STH infections and developmental outcomes among a primary school-aged population in rural China. Methodology/Principal Findings We conducted a large-scale survey in Guizhou province in southwest China in May 2013. A total of 2,179 children aged 9-11 years living in seven nationally-designated poverty counties in rural China served as our study sample. Overall, 42 percent of the sample’s elementary school-aged children were infected with one or more of the three types of STH—Ascaris lumbricoides (ascaris), Trichuris trichuria (whipworm) and the hookworms Ancylostoma duodenale or Necator americanus. After controlling for socioeconomic status, we observed that infection with one or more STHs is associated with worse cognitive ability, worse nutritional status, and worse school performance than no infection. This study also presents evidence that children with Trichuris infection, either infection with Trichuris only or co-infected with Trichuris and Ascaris, experience worse cognitive, nutritional and schooling outcomes than their uninfected peers or children infected with only Ascaris. Conclusions/Significance We find that STH infection still poses a significant health challenge among children living in poor, rural, ethnic areas of southwest China. Given the important linkages we find between STH infection and a number of important child health and educational outcomes, we believe that our results will contribute positively to the debate surrounding the recent Cochrane report.

Dropping Out of Rural China's Secondary Schools: A Mixed-methods Analysis*

Students in rural China are dropping out of secondary school at troubling rates. While there is considerable quantitative research on this issue, no systematic effort has been made to assess the deeper reasons behind student decision making through a mixed-methods approach. This article seeks to explore the prevalence, correlates and potential reasons for rural dropout throughout the secondary education process. It brings together results from eight large-scale survey studies covering 24,931 rural secondary students across four provinces, as well as analysis of extensive interviews with 52 students from these same study sites. The results show that the cumulative dropout rate across all windows of secondary education may be as high as 63 per cent. Dropping out is significantly correlated with low academic performance, high opportunity cost, low socio-economic status and poor mental health. A model is developed to suggest that rural dropout is primarily driven by two mechanisms: rational cost-benefit analysis or impulsive, stress-induced decision making.

Intended And Unintended Consequences Of China’s Zero Markup Drug Policy

Since economic liberalization in the late 1970s, Chinas health care providers have grown heavily reliant on revenue from drugs, which they both prescribe and sell. To curb abuse and to promote the availability, safety, and appropriate use of essential drugs, China introduced its national essential drug list in 2009 and implemented a zero markup policy designed to decouple provider compensation from drug prescription and sales. We collected and analyzed representative data from Chinas township health centers and their catchment-area populations both before and after the reform. We found large reductions in drug revenue, as intended by policy makers. However, we also found a doubling of inpatient care that appeared to be driven by supply, instead of demand. Thus, the reform had an important unintended consequence: Chinas health care providers have sought new, potentially inappropriate, forms of revenue.