Effectiveness of provider incentives for anaemia reduction in rural China: a cluster randomised trial

Sample schools were randomly assigned to a control group, with no intervention, or one of three treatment arms:
(a) an information arm, in which principals received information about anaemia namely how many students in the school were affected, how to reduce it and the relationship between anemia and academic performance;
(b) a subsidy arm, in which principals received the same information as treatment (a) along with subsidies to be spend towards nutritional supplement for reducing anaemia; and
(c) an incentive arm, in which principals received information, subsidies, and financial incentives for reducing anaemia among students.

2009-11-01

2010-05-31

1) Haemoglobin concentration in students
2) Anaemia status of students after the intervention

1) Haemoglobin concentration in students: haemoglobin concentration directly using finger prick blood samples (with HemoCue 201+)
2) Anaemia status of students after the intervention : same as above

Through a canvass survey, a sampling universe of all primary schools in 10 nationally designated poor counties spread across two provinces with high anaemia rates—Ningxia and Qinghai – was created. Schools having six grades (“complete” primary schools) and boarding facilities were shortlisted. A total of 85 schools met these criteria, and 72 were randomly selection for inclusion into the study.
Half of the fourth and fifth grade students in sample schools were randomly selected as study participants. Fourth and fifth grade students were chosen because they are old enough for test scores to be relevant but also young enough not to have reached puberty (at which point nutritional requirements differ more markedly from childhood and vary by sex).

Baseline and follow-up surveys were conducted for all principals and students in the sample schools. Students were tested for their hemoglobin levels through finger pricks. Household surveys were also conducted for all study participants.

Done using STATA 10

School

Yes

72 primary schools

3944 students

Control: 27 schools, 1816 students
Treatment 1 (information arm): 15 schools, 659 students
Treatment 2 (subsidy arm): 15 schools, 726 students
Treatment 3 (incentive arm): 15 schools, 743 students

Using estimates from previous studies, it was calculated that 30 schools (15 per trial arm) and 55 students per school for each inter-arm comparison was required to detect a standardised effect size of 0.4 for haemoglobin concentration with 80% power at the 5% significance level.

EFFECTIVENESS OF PROVIDER INCENTIVES FOR ANAEMIA REDUCTION IN RURAL CHINA: A CLUSTER RANDOMISED TRIAL

OBJECTIVE: To test the impact of provider performance pay for anaemia reduction in rural China.

DESIGN: A cluster randomised trial of information, subsidies, and incentives for school principals to reduce anaemia among their students. Enumerators and study participants were not informed of study arm assignment.

SETTING: 72 randomly selected rural primary schools across northwest China.

PARTICIPANTS: 3553 fourth and fifth grade students aged 9-11 years. All fourth and fifth grade students in sample schools participated in the study.

INTERVENTIONS: Sample schools were randomly assigned to a control group, with no intervention, or one of three treatment arms: (a) an information arm, in which principals received information about anaemia; (b) a subsidy arm, in which principals received information and unconditional subsidies; and (c) an incentive arm, in which principals received information, subsidies, and financial incentives for reducing anaemia among students. Twenty seven schools were assigned to the control arm (1816 students at baseline, 1623 at end point), 15 were assigned to the information arm (659 students at baseline, 596 at end point), 15 to the subsidy arm (726 students at baseline, 667 at end point), and 15 to the incentive arm (743 students at baseline, 667 at end point).

MAIN OUTCOME MEASURES: Student haemoglobin concentrations.

RESULTS s 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 a 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.

CONCLUSIONS: Financial incentives for health improvement were modestly effective. Understanding interactions with other motives and pre-existing incentives is critical.

Miller, Grant, Renfu Luo, Linxiu Zhang, Sean Sylvia, Yaojiang Shi, Patricia Foo, Qiran Zhao, Reynaldo Martorell, Alexis Medina, and Scott Rozelle. "Effectiveness of provider incentives for anaemia reduction in rural China: a cluster randomised trial." BMJ e:4809 (2012): 1-10. doi: 10.1136/bmj.e4809.

http://www.bmj.com/content/bmj/345/bmj.e4809.full.pdf