Nutrition and Healthcare for Children from Rural Tibetan Households

Full text

68
Domestic
1. Introduction
Nutrition and healthcare are key factors for
development, especially at early ages (Van der
Gaag, 2011). Access to a nutritional diet and good
practices of child raising and disease prevention
will simultaneously reduce disease and
mortality rates as well in addition to preventing
malnutrition and stunted growth. Children having
access to nutrition and healthcare services will
not only have appropriate height, weight and
cognitive and non-cognitive abilities (character
and emotion) but also be less likely to suffer
from chronic diseases. Adequate nutritional and
healthcare for children will in effect improve
the quality of the workforce, expand labor
participation and contribute to economic growth.
In the early 21st century, international
development organizations and scholars of
various disciplines produced studies on early child
development such factors as nutrition, healthcare
and education.1 Nutrition and healthcare issues
have received much less attention than education
from Chinese policymakers and most scholars.
Fortunately, the “12th Five-Year Plan” launched
a nutrition improvement program impacting 26
million rural middle and primary school students
across 669 impoverished counties. At the end of
2012, child nutrition intervention pilot programs
began to provide nutrition allowance for children
aged between 6 and 24 months in eight poverty-
stricken areas covering 100 rural counties across
ten provinces and autonomous regions2.
Nutrition and Healthcare
for Children from Rural Tibetan
Households*
Zhu Ling (朱玲)
Institute of Economics, Chinese Academy of Social Sciences, Beijing, China
Abstract: Three major programs have been implemented in rural Tibetan areas in order
to improve children’s nutrition and healthcare, namely antenatal care, infant and young
child feeding, as well as school feeding. In terms of effectiveness of service provision, the
school feeding program has been put into practice more effectively than the other two for
two reasons. First, rural Tibetan families are accustomed to traditional infant and young
child feeding practices. Secondly, the lack of incentives for healthcare workers and the
shortage of funding have hindered the provision of healthcare to rural families. Therefore,
this paper proposes an adjustment of the incentive structure for healthcare providers, a
fortification of the village level network of healthcare services, an improvement in the
approach to healthcare education for farmers and herders, and the coordination of training
courses targeted at the ofcials and service teams of the healthcare system.
Keywords: Tibetan children, rural families, nutrition and healthcare
JEL Classication: I12, I18, I38
* Corresponding author: zhuling@cass.org.cn
The author would like to acknowledge the contribution of
literature by Deng Quheng and Zhao Chen and discussion by Chen
Chunming, Luorong Zhandui, Danzeng Lunzhu, Wang Dan and Zha
Luo in the course of this study.

69
China Economist Vol.9, No.3, May-June 2014
Due to reasons mentioned above, over
the past 30 years, very few Chinese scholars
have carried out studies on child nutrition and
healthcare in Tibet. Nutritionists at the Chinese
Center for Disease Control and Prevention
conducted multi- rounds sample surveys on the
nutrition status of children in both urban and
rural areas, but their samples did not include
rural Tibet (Chen Chunming, et al., 2010; Chen,
et al., 2010). In the child development studies
conducted by the China Development Research
Foundation, only one survey carried out in Ledu
County of Qinghai Province includes Tibetan
families (Hao Zhirong, 2012). Luorong Zhandui,
a scholar from the China Tibetology Research
Center, twice visited ten rural primary schools
in Lasa (Lhasa) City, Shannan and Rikaze
prefectures in 2000 and 2010. For each visit, he
measured the height and weight of 300 ten-year-
old children. In the 2010 study, the average height
and weight of children is 125.6cm and 23.5kg.
Compared with the result of measurement in
2000, height and weight averages for children
had increased by 5cm and 2.5kg respectively.3
Unfortunately, the measurement records do not
contain gender-specic data. In 2010, the women
and children’s healthcare system of Changdu
(Qamdo) Prefecture conducted a survey on 3,887
children under the age of ve yet without gender
and urban-rural classication. The survey report
did not stated methodology of statistics and the
stunting rate of the surveyed children. It only
shows that the rate of low weight of the surveyed
children below the average level of the poor
region in China, which implies that the nutrition
status of the children in Changdu is better in this
respect.4 Without access to original data though,
it is difficult to assess the accuracy of such
statistics.
Since the 1990s, international scholars
have published the following findings on child
nutrition and healthcare conditions in Tibetan
Autonomous Region (TAR) and Tibetan areas of
Qinghai Province:
First, the altitude of Tibetan plateau makes
an impact on childhood nutrition. Between 1994
and 1995, Nancy Harris et al. (2001) carried
out a survey of the parents of 2,078 children
from immediately after birth to seven years old
in eleven counties of five prefectures through
collaboration with local healthcare officers
in Tibet Autonomous Region. Their results
show that the ratio of stunted child growth is a
staggering 51%. According to the location of
sample towns and townships, Harris et al. believe
that child malnutrition is not correlated directly
with altitude but is correlated with community
medical conditions. For instance, among children
two years old and above, stunted growth ratio
is 35% for children in urban areas and 60% for
children in rural areas (Harris, et al., 2001).
According to a 1999 study conducted
jointly by the medical school at Xi’an Jiaotong
University and the - University of Tokushima
(Japan) in 29 counties and 145 townships
in TAR, altitude has a major effect on the
physical development of children in this region,
particularly on their height. Their results indicate
1 See the World Bank webpage: Why Invest in Early Child
Development (ECD),
http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/
EXTCY/EXTECD/0,,contentMDK:20207747~menuPK:527098~pa
gePK:148956~piPK:216618~theSitePK:344939,00.html, November
17, 2012.
2 Fan Xiaojian: Speech at the Opening Ceremony of the 3rd
International Symposium on Poverty Relief and Child Development,
Beijing, October 18, 2012.
3 For this survey on the weight and height of Tibetan children,
I asked for measurement table and result from Luorong Zhandui.
Reporters with People’s Daily also covered his survey but misstated
the data about the change in children’s weight. See people.com.cn:
Tibetan Researcher Luorong Zhandui: Unprecedented Improvement
in the Livelihood of Tibet, August 13, 2012, http://xz.people.com.cn/
n/2012/0813/c138901-17351477.html, March 3, 2013.
4 There is the following statement in Analysis Report on
Women’s and Children’s Healthcare Annual Report 2010 for
Changdu Prefecture: “nutrition survey included 3,887 children
below ve years of age, including 201 with median weight -2SD.
Incidence of malnutrition is 5.17%, up 2.83 percentage points
over the level of 2.34% in 2009”. (Source: Qamdo Healthcare
Bureau, March 2, 2011). By the WHO standards, child nutrition
indicator value Z=(W-RM)/SD. Where, W is the height or weight
of sample under observation; RM is the WHO reference criterion
(median value of height or weight); SD is standard error for the
WHO reference criterion (height or weight). By such calculation,
low weight rate of children under five years of age in rural poor
regions of China in 2009 is 6.6% and stunting rate is 18.3% (Chen
Chunming et al., 2010).

70
Domestic
that among children under age three, the ratios
of stunted growth and underweight are 39.0%
and 23.7% respectively compared to 25.3%
and 18.1% for urban children and 41.4% and
24.7% for rural children. Stunted growth and
underweight ratios for children in herding areas
are higher than those in farming areas (Dang,
et al., 2004; 2008). In fact, altitude is seen as
dummy variable affecting childhood nutrition
and healthcare conditions. Urban, farming
and herding areas are in an ascending order
of altitude, and the higher altitudes frequently
experience harsh environmental conditions and
offer weaker infrastructure and social services,
such as healthcare.
Second, the following socioeconomic factors
affect childhood nutrition and health: maternal
health, childhood feeding practices and integrated
factors from living environment to healthcare
offerings. First, in 2004, Mary Wellhoner et al.
carried out a questionnaire survey on 402 women
of childbearing age in Xiaosumang Township
in collaboration with the Maternal Healthcare
Institute of Yushu County, Qinghai Province. The
study concluded that it was very difcult for local
women and newborns to access institutionalized
healthcare services, which results in high
maternal and infant mortality (Wellhoner, et
al., 2011). Second, the aforementioned study
by Xi’an Jiaotong University and University of
Tokushima provided a questionnaire for mothers.
According to the responses of 1,655 mothers,
their breast-feeding period is averaged at 26
months. Of them, 20.1% had a pure breast-
feeding period of four months and the others
added roasted barley flour paste one month
after giving birth. When an infant reached six
months, less than 25% of mothers fed their
children with egg and meat and 20% provided
fresh vegetables. Scholars concluded that lack of
variety in diet was a key problem in child feeding
in rural Tibetan areas (Dang, et al., 2005). Lastly,
in 2003, Kunchok Gyaltsen et al. selected 10
villages in two townships and interviewed 280
women of childbearing age in two counties of
Tibetan areas of Qinghai Province for a survey on
their socioeconomic attributes, living conditions,
community environment, medical services and
childcare. Gyaltsen et al. discovered that diarrhea
and respiratory infections were common among
local children, particularly those suffering from
malnutrition. The same was true for places with
poor hygiene and sewage discharge facilities.
They also emphasized that lack of maternal
healthcare services were a major reason for infant
and maternal mortality (Gyaltsen et al., 2007).
These sample survey results reect childhood
nutrition and healthcare conditions and their
decisive factors in Tibet between 1994 and 2003.
Afterwards, the central government introduced a
series of major public healthcare programs and
investment projects for improving livelihood
of rural people, which have transformed Tibet’s
socioeconomic landscape. These efforts would
have made an impact on child nutrition and
health, but this policy intervention failed to draw
adequate attention from researchers. Additionally,
the existing reports provide only statistical data
and analysis. The qualitative studies are not
sufcient.
Based on field visits conducted in Gongjue
County and Jiangda County in the TAR and Dege
County in Sichuan Province in 2011, this report
focuses on three research questions. First, what
do maternal healthcare programs contribute to the
improvement in women and children’s healthcare
services? Second, have child and infant feeding
practices changed in light of evolving living
conditions for farmers and herdsmen? Third, what
are the effects of school feeding programs on the
diet and health of pupils?
Responding to these questions requires an
observation and evaluation of relevant public
policies, a review of the government’s policy
implementation and policy recommendations.
Thus, this study has adopted the case study
approach and visited the healthcare bureau of
the Changdu Prefecture in TAR, the healthcare
bureaus and county hospitals in the three studied
counties, ve township healthcare centers, three
township primary school kitchens, six village
committees, the healthcare workers, the pregnant
women and the mothers with infant or young
child in the villages. In 2005, this study conducted
a healthcare service survey in the Ganzi Tibetan
Autonomous Prefecture in Sichuan Province and

71
China Economist Vol.9, No.3, May-June 2014
Changdu Prefecture in the TAR. The first-hand
information collected from that survey could be
used as a reference.
In light of the recent policies for certain
groups, this report discusses the improvement
in nutrition and healthcare of pregnant and
breastfeeding women, children aged between zero
and two and primary school students. Commonly,
nutrition and healthcare programs for children
between three and six years old are executed at
the kindergarten level, but the necessary facilities
are lacking in rural Tibetan villages.
2. Maternal Nutrition Intervention
and Healthcare Services
The 2007 report released by the World
Health Organization put emphasis on a fact that
appropriate nutrition is essential to a child’s
survival. Mothers must also acquire sufficient
nutrition during pregnancy (Siddiqi, et al.,
2007). According to the Report on Nutrition
Development for Chinese Children aged between
0 and 6 released by the China’s then Ministry
of Health, maternal and childhood nutrition in
the first 1,000 days after inception will have
long-term impacts on the health of the child.
Malnutrition in this stage will lead to irreversible
and irreparable damage. Short-term effects
include retarded physical and mental development
and an increased incidence of disease. Long-
term effects include the loss of cognitive abilities
and increased risk of chronic diseases such as
cardiovascular disease, diabetes and hypertension
(Chinese Ministry of Health, 2012). Maternal
healthcare services not only ensure that a child
can start his or her life well but also effectively
reduce maternal and infant mortality.
The prenatal care program was launched in
2000 to reduce maternal mortality and eliminate
newborn tetanus. Under this program, rural
women are entitled to a 500-yuan allowance per
person for the hospitalized childbirth. Under
the defective-birth prevention program, free
supplements of folic acid are provided to women
three months prior to their due date and after their
pregnancy to prevent neural tube defection. In
rural Tibetan areas, the program provides vitamin
A capsules.5 As international experience suggests,
these services can effectively reduce maternal and
infant mortality as well as defective birth, thereby
improving widespread access to healthcare.
Free and subsidized access to maternal services
provides an obvious benefit to rural Tibetan
households. However, these very households did
not respond actively to the programs due to lack
of knowledge, information and services (Zhu
Ling, 2008).
First, maternal healthcare services in rural
Tibetan areas did not fully reach the target groups.
In townships and villages adjacent to public
roads, some target women received free medicine,
however, in less accessible places, pregnant
women and their families reported that they had
not known about free nutrition supplements.
When asked about their pregnancy, most
respondents said that they delivered their babies
in their own home (or tent) with the assistance
of their family members, relatives or female
neighbors. A woman aged 34 delivered three
times at home. Her husband cut off her umbilical
cord using a thin rope, which caused excessive
bleeding. She remained too weak to engage in
outdoor work since she delivered her third child.
Another respondent said that his wife cut off her
own umbilical cord using an unsterilized knife
and died less than one month later due to the
resulting complications. Moreover, pre-delivery
check, post-delivery visits and the use of sterilized
instruments for non-hospitalized delivery were
still uncommon. Healthcare statistics in surveyed
areas also suggest that maternal healthcare
services were yet to reach key policy targets. In
2010, the hospitalized maternal delivery ratio
was 47.4% in the Changdu Prefecture; the rural
women’s hospitalized delivery ratio was 39.8% in
Dege County. Second, communication efforts are
insufcient. There are major gaps in the coverage
of information dissemination. Maternal mortality
reduction and newborn tetanus elimination
5 Ministry of Health, P. R. China: Regulations on Maternal
Healthcare and Good Maternal Healthcare Practices, June 23,
2011, http://www.moh.gov.cn/mohfybjysqwss/s3581/201107/52320.
shtml, March 14, 2013.

72
Domestic
program as well as defective-birth prevention
program have included the promotion of
knowledge and service information. Banners are
put up and leaets are distributed in county areas
on theme publicity days or on the occasion of
holiday fairs. Township healthcare centers have
also put up posters. These practices are useful, yet
insufcient to reaching target groups.
Furthermore, the transmission of key
information relating to maternal service
provision was neglected. The new Rural Medical
Cooperative, referred to as the Rural Tibetan
Medical System in TAR, had become popular
in studied counties.6 The TAR government
stipulated that the costs of the non-hospitalized
childbirth service with disinfection measures
provided by the healthcare workers can be
reimbursed from the funds of the Rural Tibetan
Medical System when the medical bills are
verified with the signature of the delivery
woman or her family members. The stipulation
is apparently appropriate arrangement favorable
to the women and their families living in very
remote villages. However, such key provisions
were omitted in the implementation regulations
issued by the Changdu Prefecture. Moreover,
some recent supplementary provisions were
yet to be informed to rural households, such
as, for instance, if a pregnant woman from a
Dibao household, one which is protected under
minimum subsistence guarantee system, opts
for hospitalized delivery, they are entitled to
an subsidy of 100 to 500 yuan in addition to
the regular reimbursement of healthcare costs,
maternity benets and transport allowance. Some
households still benefit from certain services.
For example, a nine-month pregnant woman in
Hajia Township in Gongjue County asked a lama
about her pregnancy-related discomfort, and the
lama told her to see a doctor. She then received
an inspection at a county hospital, where she was
diagnosed with abnormal position of the fetus.
Another pregnant woman in Tongpu Township in
Jiangda County also went to the county hospital
twice for prenatal check following the advice of
the village healthcare worker, who also happened
to be a village cadre. The village healthcare
worker gave her nutritional supplements two or
three times, and she asserted that she took them
all. In order to determine the venue of delivery,
she visited Wala Temple and was told by the
Living Buddha to have a hospitalized delivery.
As a result, her parents were prepared to escort
her to the county hospital. These instances show
that pregnant women and their families in rural
Tibetan areas will seek information from their
trusted sources. Sufficient dissemination of
healthcare information to households is essential
to the utilization of maternal healthcare services.
Third, the lack of effective information
delivery is a reection of inadequate management
of healthcare services. Healthcare bureau ofcials
in surveyed counties ascribed this problem to
the following reasons. First, residences of rural
Tibetan households were scattered, and healthcare
workers were inadequate at the grassroots level.
Furthermore, there had been a brain drain due to
harsh living conditions in high-altitude regions
and unattractive compensation. Tightening
management would make healthcare staff even
less willing to stay.
In fact, these circumstances can be
ameliorated. As a growing number of Tibetan
medical graduates are hired by township
healthcare centers, healthcare quality at the
grassroots level has been improved. Due to the
scarcity of jobs in Tibet and the employment
security in the public sector, these graduates take
their jobs very seriously. Moreover, a steady
increase in investment into Tibet’s infrastructure
and public service in Tibet has improved heath
financing, medical equipment and buildings of
public healthcare providers.
6 In 2010, medical nancing standard for rural Tibet is RMB
260 yuan per head and this gure is RMB 130 yuan for the new rural
cooperative program of Dege County, Ganzi Prefecture, Sichuan
Province. Contribution requirement for both regions is the same, i.e.,
RMB 20 yuan per person from rural households and the rest comes
from government allowance. In addition, insurance participation for
poor households is paid by civil affairs departments on their behalf.
Insurance participation ratio for the three counties under survey are
all above 90%.
7 65th WHA: Maternal and Infant Nutrition, June 2012
http://www.moh.gov.cn/wsb/01100214/201206/55094/les/e3b
7441a4a274b0686b40bef9a8c7ca0.pdf, March 15, 2013.

73
China Economist Vol.9, No.3, May-June 2014
The lack of incentive for healthcare workers
and management of healthcare services present
areas with room for improvement. In fact, some
excellent healthcare workers reported leaving
Tibet because they felt unsatisfied regarding
the lack of professional incentives. Township
administrative ofcials were frequently appointed
to be county-level healthcare officials without
necessary training—they lacked experience in the
healthcare sector and did not know much about
good management practices from other parts of
China. For instance, they were unfamiliar with the
evaluation of healthcare services and the practice
of compensating healthcare staff according to the
quality of service.
Hence, it is necessary to adopt the following
measures in order to improve the maternal
healthcare management of women in rural
Tibetan areas:
(1) Management capacity training focusing
on case studies of successful maternal healthcare
management experiences for township and
county officials should be a top priority for
Tibetan assistance programs. For instance, the
China Foundation for Poverty Alleviation carried
out a maternal and infant protection program in
the mountainous areas of Yunnan Province to
ensure delivery of services to households through
the creation of a three-tier maternal and child
healthcare network. Physicians at the township
healthcare center of Chun’an County, Zhejiang
Province were assigned to households in various
areas at which they were to conduct regular visits
as family physicians.
(2) Maternal and child healthcare
management responsibilities should be fulfilled
at the household level and incorporated into the
assessment of grassroots healthcare institutions
and staff. Service providers should be subsidized
for the maintenance and fuel costs of transport
vehicles such as motorcycles.
(3) Family planning and maternal healthcare
services should be integrated. Although
county healthcare bureau and family planning
commissions in surveyed counties had been
combined namely, the organizations operated
independently. The family planning commission
holds adequate funding and mobile healthcare
equipment while healthcare institutions, which
boast strong technical service capabilities. Their
comprehensive integration will create a more
effective system overall.
(4) Village committee members should be
involved in dissemination of health knowledge
and t information. These activities should also be
supported with public nance.
3. Infant and Young Child Feeding
According to the Global Strategy for Infant
and Young Child Feeding (IYCF) adopted at the
55th World Healthcare Assembly (WHA) in 2002,
a total of 10.9 million children below the age of
five die each year. At this age, roughly 60% of
mortality results from malnutrition, and more than
two thirds are related to inappropriate feeding
in the child’s rst year. The report explains that
breast milk should be the only food and drink
to infants for their first six months. After six
months, infants will require safe and nutritious
supplementary food in addition to the nutrition
they receive from breastfeeding. The WHA called
on member states to implement these baseline-
feeding conditions for infants and young children
to reduce malnutrition and risk of relevant
diseases (the World Health Organization and
UNICEF, 2003). The 65th WHA, held in 2012,
adopted a comprehensive scheme on maternal
and childhood nutrition, further requiring member
states to elevate childhood nutrition to a key
national priority and incorporate it into national
development projects.7
In addition to proactive participation in the
deliberation and voting of the WHA, the Chinese
government has released the Infant and Young
Child Feeding Strategy (MOH, 2007). This
document has demonstrated that breastfeeding
can provide all of the nutrition required for
infants below six months of age. Breast milk
contains abundant anti-bacterial benets and that
breast-fed infants are less likely to suffer from
diarrhea, respiratory and skin infection. Breast
milk contains many amino acids necessary to the
cerebral development of infants. Also a mother’s
voice, embrace and touch during the process
of breastfeeding can stimulate her baby’s brain

74
Domestic
response and stimulate early intellectual and
psychological development. Infant and Young
Child Feeding Strategy calls for the establishment
of infant care standards for hospitals and health
education avenues to extend strictly breastfeeding
for newborns for the rst six months after birth.
Moreover, the report advocates pre-job and on-
the-job training to enhance the knowledge and
skills of healthcare staff regarding infant dietary
supplements, continued breastfeeding and special
infant feeding practices.
This part of the paper will discuss childhood
feeding practices in rural Tibetan households.
According to a survey on women and children
in TAR conducted in 1999, roughly 80% of
breastfeeding-period women provide roasted
barley our paste to their children one month after
birth.8 The Changdu Healthcare Bureau reported
in 2011, 94.7% of the 4, 066-breastfeeding
women who were surveyed breastfed their babies
under the age of six months, and of them, 51.1%
fed their children only breast milk for the first
six months.9 It seems that more women had
chosen to breastfeed their babies than ten years
before. However, by our field visit in the same
year it is found out that most of the interviewed
rural women still adhered to the traditional baby
feeding practices.
The duration of breastfeeding corresponds
to the interval between two births. A 40-year-old
pregnant woman in Shadong Township, Gongjue
County mentioned that she had given birth to
four children, one of who had died. She breastfed
each child for two years, added roasted barley
our paste after the rst two months and included
meat after one year. A woman at the same age
in Hajia Township reported that she breastfed
each of her children. She stopped breastfeeding
her oldest daughter when she was one year old
and her younger son around the age of four or
ve. Nevertheless, she added roasted barley our
paste, butter and milk soon after birth of each
child. In the interviews, the respondents stated
that they rst chewed roasted barley our paste
then used their ngers to take out some to feed
babies. Such feeding takes place three or four
times a day, and each time a baby was fed only
one or two mouthfuls. As an infant grows up,
the quantity of feeding increased as well. Often,
when a child reached two years of age, he/she
would eat roasted barley our paste by himself/
herself and whatever else adults ate. Respondents
indicated that they had not known or heard about
the recommendation from the health service
institutions that mothers should feed newborns
only with breast milk for the rst six months and
then start to provide supplementary diet.
The similar way of the infant and young
child feeding is found in the counties of Jiangda
and Dege. Nevertheless, it is noticed that the
households with better living conditions and
higher incomes provided their babies with a
greater variety of supplementary food. Tongpu
Township in Jiangda County is located near the
public road No. 317 and is over 20 kilometers
away from the county seat. A shuttle bus operated
by the nearby Wala Temple provides service to
and from the county town for RMB 12 yuan a
one-way ticket. The author interviewed a 29-year-
old pregnant woman in Xiawo Village, in which
three generations of her family members shared
the same house. With ten family members, four
taught or worked outside the village and brought
about a stable cash income. By the time her rst
daughter was four months old, her family added
milk, roasted barley our paste, butter, vegetables
and meat to the infant’s diet. In Lengcha Village
of Baiya Township, 40 kilometers away from the
county town in Dege, the health worker at the
village was interviewed. His daughter and son
in-law went to Lhasa city to work such that his
grand children were weaned with breast milk at
the age of six months, and their daily diet also
consist of the ve types of food indicated above.
According to the Infant and Child Feeding
Strategy released by the Ministry of Health, the
following three challenges remained present in
8 Dang, S., H Yan, S Yamamoto, X Wang and L Zeng:
《Feeding Practice among Younger Tibetan Children Living at High
Altitudes》, 《European Journal of Clinical Nutrition》, 2005, No.
59, pp. 1022–1029.
9 Qamdo Healthcare Bureau: Report on Annual Data of Women
and Children’s Healthcare in Changdu Region 2010, March 2, 2011.

75
China Economist Vol.9, No.3, May-June 2014
the manner in which rural Tibetan households fed
their infants. First, the duration of breastfeeding
was too short and the provision of supplementary
nutrition occurred at too young an age. Second,
infants were fed with food chewed by adults,
which presented risks for infection for the
children’s vulnerable immune systems. Third, the
supplementary diet was not sufficiently diverse
for far-located markets. The first two problems
were directly related to the lack of knowledge
in rural areas. The members of the households
interviewed reported that children had been fed
in this manner for generations. The explanation
given by the Tibetan scholars interviewed in
Beijing are as varied as follows:
First, if breast milk was sufciently available,
roasted barley flour paste was usually not
provided before a newborn reached six months
of age, but butter was. In general, Tibetans view
butter as a very nutritious food, but difficult to
digest. Therefore, they diluted butter with roasted
barley and tea when feeding it to infants.
Second, roasted barley mixed with buttered
tea can prevent diarrhea regardless of whether
a mother has sufficient breast milk. Adults
traditionally chew meat before feeding it to
infants, and the parents themselves report being
fed in this manner.
Third, roasted barley flour paste is a warm
food. It is nutritious, digestible and the only
supplementary diet appropriate to babies in rural
Tibetan villages.
These replies were based on conventional
experience, and respondents were not familiar
with the differentiation between “pure
breastfeeding” and “breast milk feeding.” The
author consulted Professor Chen Chunming, a
nutritionist at Chinese Center for Disease Control
and Prevention, regarding the above explanations.
Her responses are below. First, providing a
newborn with only breastfeeding before he
or she reaches six months of age ensures a
comprehensive and safe supply of nutrition. The
provision of supplementary food prior to the six
months will be unfavorable for the development
of the child’s digestive system, and may even
damage digestive functions and increase the
risk of mortality. Second, traditional ways of
feeding in rural Tibetan villages are neither safe
nor nutritious, as asserted by a Tibetan physician
in Boluo Township in Jiangda County. He said
that the most common illness for local children
is indigestion during the breastfeeding period.
Improper ways of feeding can partially explain
why the ratios of low weight and stunted growth
of children under the age of ve in rural Tibetan
areas are higher than national average. In 1998,
the ratio of low weight and stunted growth for
children under the age of five were 9.8% and
27.9% respectively (Chen Chunming et al.,
2010). For comparison, in 1999, the low weight
and stunted growth ratios of children below the
age of three were 24.7% and 41.4% (Dang, et al.,
2004; 2008).
Based on the information above, we may
suppose that in the distant past, there was no food
security in Tibetan region and women suffered
from malnutrition. They were unable to provide
sufficient nutrition to their infant children, and
had to add adult food into their diet. Gradually,
this feeding practice became a local custom,
and young parents added supplementary food in
the diet of newborns at the age of three to four
months or younger. Infants had often suffered from
diarrhea, and some had died as a result of this
practice. The parents were not aware of the true
reasons for their child’s gastrointestinal diseases
and did not realize that numerous fatalities of
infant and young children resulted from improper
feeding. For the same reason, government and
healthcare institutions in rural Tibetan areas
did not give sufficient attention to the hazards
resulting from traditional ways of feeding.
In the households’ visits, the author asked
extensively about the diet of pregnant women and
breastfeeding women. Respondents indicated that
they had no problem of food variety; however,
the level of diversity in their diet depended on the
types of self-produced food, family income and
distance to the nearest food market, which were
usually located at the county towns. For instance,
a 140 kilometers ride separates Geluo Village,
Shadong Township in Gongjue County and the
local county town, a three-hour ride in an SUV
in good conditions. This village was specialized
in growing staple food crops while vegetables

76
Domestic
were planted around each residence. A pregnant
woman in the village said that she relied on butter
and roasted barley and rarely ate meat during the
pregnancy and breastfeeding period. Vegetables
were not available until the weather became
warm.
While feeding her baby, Bo Ga (a
pseudonym), a woman in Bairi No. 2 Village
of Yulong Township, Dege County stated that
during her pregnancy for her sixth son who had
been born three months before, she just had a bit
more beef soup than her family members did.
Her family received a Dibao subsidy (a minimum
subsistence guarantee) and purchased roasted
barley powder, butter, beef and vegetables from
the nearby Mani Gange Market. In comparison,
the pregnant woman of a rich family in Tongpu
Township in Jiangda County ate a more varied
diet—her diet included butter cooked with roasted
barley, rice, potato, cabbage and occasionally
beef. Since her pregnancy, she had eaten chicken
meat and drank chicken soup, beef soup and sh
soup. When asked about cost of additional food,
she smiled and kept silent. It turned out that this
family’s money manager was her father-in-law
(59 years of age). He replied “about RMB 2,000
yuan.”
Short duration of only breastfeeding and a
lack of nutrition and safety in the supplementary
food provided to infants represent problems
that are still prevalent among rural Tibetan
households. Such feeding practices are closely
related to the traditional customs of Tibetan
society. It is then expected that health education
would provide substantive improvements in
childhood nutrition. One-on-one and face-to-
face guidance must be provided to pregnant and
breastfeeding women. In particular, nutrition and
health knowledge should be included in primary
and middle schools’ health courses. These efforts
will require public healthcare institutions to
provide careful, solid and effective door-to-door
service across remote areas of Tibet.
The statistics issued by the Changdu Health
Bureau in 2010 indicated that health management
services had covered 62.6% of children under the
age of seven and 57% of newborns had received
home visits. The dissemination of necessary
information on infant and young child feeding,
however, lacked strategy and effectiveness. In
2012, the health service system in TAR began to
enhance child health management. For instance,
the Health Bureau of the TAR requires at least
two visits for newborns and at least four uses of
child health services within the first year after
birth. The scope of services ranges from physical
checkups and growth monitoring to breastfeeding
analysis, psychological development review, the
prevention of accidental injury and guidance on
the prevention and treatment of common diseases.
Currently, the question is what kind of incentive
should be provided to ensure that grassroots
healthcare staff fulfill these requirements and
promote the targeted groups to take action.
This is consistent with resolving the challenges
confronting maternal healthcare services. The
policy measures identied in the previous section
may apply as well.
4. Primary School Feeding
Management
The policy of free meals for primary and
middle school students has proven to be widely
applauded according to the studies of our
research team. In 2005, the team documented
the efforts made by Changdu Prefecture, eye
witnessing township officials and village
leaders visiting each household to persuade
parents to allow their children to attend school.
By 2010, however, with the exception of the
children who studied Buddhism in monasteries,
enrollment of school-aged children in Tibet had
already approached almost 100%, indicating
the effectiveness of the policy on obligatory
education. Government policies of free school
lunches, free accommodation and no tuition fees
have undoubtedly reduced the cost of raising
children in rural Tibet. In particular, the school
meals are often much healthier, safer and more
delicious than the family meals, which has
made attending school more attractive to rural
Tibetan children. As also seen in international
experiences, the free school meals have not only
resulted in the increased cognitive abilities and
academic performance of the children but also

77
China Economist Vol.9, No.3, May-June 2014
improved the nutrition and healthcare of the
children. Therefore, free school meals represent a
human capital investment with a long-term return
(Bang Di, et al.). In 2011eld visits of the team,
the following became very noticeable.
First, the free school meals bring benets in
dietary hygiene and food safety to the children. In
rural Tibetan areas, primary schools with kitchens
and dining halls are all located near township
centers with boarding facilities. These buildings
are frequently newly constructed and not far from
healthcare institutes. A health worker of Baiya
Township in Dege County checks food hygiene
of the adjacent primary school kitchen on a daily
basis. Under his escort, the author interviewed
Chef Bai Zhen and Principal Mr. Zou. The school
has a tidy and bright kitchen and both the stove
and the bench of schoolchildren are furnished
with white tiles. Shining stainless steel kitchen
utensils were organized neatly. The kitchen of the
central primary school in Hajia Township, Gongjue
County was not as well organized neat but equally
well-equipped. In addition to above-mentioned
kitchen equipment, there was a stainless steel
steamer and an electric butter tea mixer.
The school kitchens described above boasted
a level of hygiene uncommon in ordinary rural
Tibetan households encountered during the study.
Both the kitchen and dining hall have access to
tap water, which is convenient for the chefs and
children to maintain hygiene standards. Of the 60
children in the school, 40 were boarding. Once
ill, children are immediately sent to the township
health center and if the condition becomes worse,
parents are telephoned to take them home. Many
villagers have telephones and can be reached in
time.
Second, the school-feeding program also
provides an otherwise unavailable diversity to the
students’ diet. A small blackboard at the entrance
of the dining hall species the menu for the three
meals of the day. During an interview, the chef
Bai Zhen reported that she had nished cooking
for lunch, a meal of steamed rice and a mixed
dish of fresh meat, lettuce, potatoes and cabbage.
She said that every morning, she woke up at six
o’clock to boil water for the schoolchildren and
began to prepare breakfast. Breakfast included
butter, roasted barley and milk tea. Lunch usually
included rice or a fried dish, and supper was
usually a noodle dish or porridge, possibly mixed
with dishes left over from the day’s lunch. At
nine in the evening, she heated water for the
schoolchildren to wash their face and feet. The
interviewed pupils stated that the school meals are
so tasty that they enjoy the food provided by the
school kitchen. Slogans on the walls of the dining
hall read “every grain of rice comes as a result of
sweat of farmers.” A small bucket in the corner of
kitchen was more than half full of buns, rice and
vegetables thrown away by schoolchildren. The
principal explained that he has not yet found an
effective way to stop schoolchildren to waste food
as they could eat as much as they wish without
any payments. Third, the food procurement system
and publicity arrangement on food expenditures
demonstrate room for improvement. The school
kitchens work for nine months each year as there
are two months of winter vacation and one month
of summer vacation. The education bureaus
in the studied counties all made rules on food
procurement, storage and consumption. According
to the principal Mr. Zou of the primary school in
Baiya Township in Dege County, authorities from
the central government, the Sichuan provincial
government and Ganzi prefectural government
jointly provide funding for primary school meals
at the level of monthly 120 yuan per student.
County education bureaus are responsible for
procuring rice, wheat our, cooking oil and other
ingredients while each school purchases its meat
and vegetables. A teacher of the school is selected
to be responsible for food storage. The principal
himself is in charge of procurement while the chef
only manages cooking. In 2010, the local price for
rice and wheat our per 500g is recorded for 1.7
yuan and about 1.6 yuan respectively. In 2011 the
prices increased to 1.92 yuan and 1.8 yuan.
Most of the meat and vegetables come from
Sichuan Province. Notably, Hajia Township in
Gongjue County utilized poverty alleviation
loans to build greenhouses and hired Sichuan
farmers to lead local resettled households
to grow vegetables. In this manner, schools
purchase vegetables from nearby farms. In 2011,
farmers from Sichuan were not available, and

78
Domestic
local resettled farmers were still unable to grow
vegetables independently. As a result, the school
and surrounding villagers had to buy vegetables
transported from Sichuan. Households in the
Yulong Township in Dege County used to be
herdsmen and now unable to grow vegetables
so that the school procured it from Mani Gange
Fair. The only foodstuffs produced locally were
barley, beef and butter, therefore, diet diversity
was primarily supplemented by non-local food
products. The school feeding program had not yet
signicantly stimulated local food production.
To the question about publicity of the food
expenditure and the supervision from the parents
of the schoolchildren, the principals of the visited
schools replied that although the parents cared
more about what their children ate than the
expenses resulting from the free meals program,
schools still published monthly expenses on the
blackboard. Deficits appeared in some of the
accounts due to inflation of food prices. Each
month the school accountant reports bills to
the local bureau of education and the bureau is
currently working on a solution.
Fourth, nutrition monitory system had not
yet been established such that the author did
not obtain access to the nutrition data of the
schoolchildren covered by the school-feeding
program.
The free meals program has been effectively
institutionalized across schools of rural Tibetan
areas. It has increased the diversity of the diet of
local children and been applauded by farmers and
herdsmen. Shortcomings in the project’s operation
are observed as follows: rst, chefs lack nutrition
education and cooking skill training; second, it
has not yet been put on the policy agenda that
funding for food procurement should be pegged
to inflation of food prices; third, a third-party
evaluation system has not been established; and
fourth, parents have not been included in the
decision-making and monitoring of the program.
5. Discussions and Tentative Policy
Conclusions
Early child development is a critical and
sensitive period for capability formation in the
life circle of the human beings. Nutrition and
healthcare in this stage provide a foundation for
a person’s development through the rest of his
or her life. Lack of early nutrition may lead to
irreparable damage to an individual’s physical
growth, cognitive abilities and emotional
development. The existing cross-disciplinary
studies indicate that investment in early child
development such as nutrition, health, care and
education provides an indispensable and most
effective tool for unlocking healthy human
development. Moreover, the earlier a child is
exposed to the investment the better the results
will be. According to a 40-year study on African-
American children, investment in pre-school
age children has an annual return of 6% to 10%,
higher than annual return to investment in school
education and on-the-job training, and even
higher than the annual return of stock market in
the same period (Heckman, et al., 2010).
However, a society often faces the following
problems: first, low-income parents may not be
informed of the knowledge about the early child
development. Second, even if a household’s
income increases, less productive expenses
compete for priority with nutrition and health. As
in financial decision-making, investment items
with a short-term horizon will inevitably enjoy
greater priority over those with long-term return.
Returns made on early child development will not
normally be realized until adulthood, so they are
often neglected. Third, once investment on early
child development is delayed, the best timing for
such investment is missed. Moreover, poverty
itself creates a negative impact on childhood
development. Public action is thus necessary to
care for poor children in their critical, early stage
of development to alleviate the negative impacts
on their growing up in impoverished conditions.
These programs allow the poor schoolchildren
to compete on a level-playing eld by reducing
the potential for the inter-generation poverty
transmission. The programs of antenatal care,
infant and young child feeding and school feeding
in rural China belong to the public actions
undertaken for poverty reduction with investment
in early child development.
The school-feeding program carried out in

79
China Economist Vol.9, No.3, May-June 2014
Tibetan townships has been implemented much
more effectively in comparison with the programs
of antenatal care and infant child feeding for
the following reasons. First, organizational
cost is relatively low—there is only one school
in each township and no more than a dozen
in each county, which provides a manageable
scope for county-level administrators in the
bureau of education. Second, the primary school
administrative network was already in place and
the implementation of the feeding program just
adds additional task to the existing administrative
networks. Third, the schoolchildren as a target
group are highly organized. Schoolchildren
are one of the groups with the strongest desire
for knowledge and sense of discipline among
residents in rural Tibetan areas, and thus they
welcome projects such as the free meals program.
Despite a partial transformation of their traditional
but less diversied diet, the substantial nutritional
improvement is consistent with the aspirations of
both the schoolchildren and their parents. Hence,
the implementation of the program met almost
no social obstacles. Fourth, as part of public
sector, schools are subject to a clear incentive
system regarding policy implementation, which
has, in this case, proven effective in encouraging
the productive implementation of the feeding
program.
The implementation of the maternal
healthcare program and the infant and young
child feeding strategy is different. First, the
agencies responsible for implementing the
programs are managing disparate rural Tibetan
households. Delivering information in person to
each household proves to be a high organizational
cost relative to the school-feeding program.
Second, the target groups of these two programs
are farmers and herdsmen with low levels of
formal education. Their receptivity to new
knowledge conflicting with traditional practices
regarding infant and young child feeding
requires long-term, careful and frequent health
education to create a worthwhile behavioral
change. Therefore, it is unlikely that this program
will demonstrate significant results rapidly.
Second, few ofcials in charge of health service
administration at county and township levels are
healthcare professionals and thus lack training
in the sector of public health, providing another
barrier to effective program operation. Third,
the relatively poor performance resulted from
the lack of qualified professional team, funding
shortage and a weak incentive structure.
Therefore, multiple actions must be taken
to enhance the quality of the program. First, the
government should stay in closer contact with the
rural Tibetan community. The village committee,
women’s groups and primary school can be
included in the healthcare program to enhance
the healthcare service network and help close
the contact between government and grassroots
community.
Second, multiple avenues of information
dissemination should be adopted to ensure
that knowledge on child nutrition be conveyed
to households, particularly to women of
childbearing age, such as television programs
popular with the rural Tibetan community, village
meetings, posterns in the homes of local citizens
and basic healthcare courses for schoolchildren.
In addition to providing the door-to-door delivery
of healthcare materials and services, such as
nutrients and health checkups, service staff
could provide childhood healthcare knowledge
to women of childbearing age and their family
members. According to existing domestic and
international experience, expanding the access
to knowledge of rural Tibetan females will
promote gender equality, which is favorable for
the improvement of early child development (the
World Bank, 2012).
Third, the incentive structure of healthcare
institutions must be improved. In addition to
pegging the salary of healthcare staff to their
quality of service, efforts could be made to
establish a healthcare monitoring system that
incorporates grassroots public opinion and
personal accountability into the evaluation
of healthcare staff. Meanwhile, third-party
assessments could provide a more independent
review on performance of healthcare and health
service administrators.
Fourth, training should be strengthened in the
aid program for Tibetan areas. Knowledge and
information about early child development should

80
Domestic
be included in the training curriculum. Beside the
managerial training and health education targeting
local ofcials and health service administrators,
courses should also be provided to the healthcare
staff, school principals and chefs who are critical
for the program.
Fifth, the superior levels of government
should allocate sufficient funding for the
operation of the programs to ensure effective
implementation. As this study was limited in its
scope, an additional study assessing the operation
of the programs in the Tibetan areas would be
benecial. Then, statistical analysis results could
be compared with the costs of similar programs
undertaken in other regions. In this way the
differences could be identified for counties at
different altitudes, with various accesses to
modern transportation and varying levels of
population density. These calculations will
provide a basis for the allocation of funding.
References:
[1] Chen, Chunming, Yuying Wang, and Suying Chang.
2010. “Effect of In-Home Fortification of Complementary
Feeding on Intellectual Development of Chinese Children.”
Biomedical and Environmental Sciences, no.23: 83-91.
[2] Cunha, F., J. J. Heckman, and S. M. Schennach. 2010.
“Estimating the Technology of Cognitive and Noncognitive
Skill Formation.” Econometrica, 78(3): 883-931.
[3] Dang, S., H Yan, S. Yamamoto, X. Wang, and L. Zeng. 2005.
“Feeding Practice among Younger Tibetan Children Living
at High Altitudes.” European Journal of Clinical Nutrition,
no.59: 1022-1029.
[4] ——. 2004. “Poor Nutritional Status of Younger Tibetan
Children Living at High Altitudes.” European Journal of
Clinical Nutrition, no.58: 938-946.
[5] Dang, S., H. Yan, and S. Yamamoto. 2008. “High Altitude and
Early Childhood Growth Retardation: New Evidence from
Tibet.” European Journal of Clinical Nutrition, no. 62: 342-
348.
[6] Gyaltsen, K., C. Gewa, H. Greenlee, J. Ravetz, M. Aikman,
and A. Pebley. 2007. “Socioeconomic Status and Maternal and
Child Health in Rural Tibetan Villages.” On-Line Working
Paper Series, California Center for Population Research,
UC Los Angeles, http://escholarship.org/uc/item/04d8b3mv,
accessed on June 23, 2012.
[7] Harris, N. S., P. B. Crawford, Yeshe Yangzom, Lobsang Pinzo,
Paldeng Gyaltsen, and M. Hudes. 2001. “Nutritional and
Health Status of Tibetan Children Living at High Altitudes.”
The New England Journal of Medicine, 344(5): 341-347.
[8] Heckman, J., S. Moon, R. Pinto, P. Savelyev, and A. Yavitz.
2010. “The Rate of Return to the High Scope Perry Preschool
Program.” Journal of Public Economics, 94: 114-128.
[9] Siddiqi, A. L. G. Irwin, and C. Hertzman. 2007. “Early
Child Development: A Powerful Equalizer: Final Report
for the World Health Organization's Commission on the
Social Determinants of Health,” http://apps.who.int/iris/
bitstream/10665/69729/2/a91213_chi.pdf, accessed on March
13, 2013.
[10] Van der Gaag, J. 2011. From Early Child Development to
Human Development – Investing in the Future of Children.
Beijing: China Development Press.
[11] Wellhoner, M., A. Lee, K. Deutsch, M. Wiebenga, M.
Freytsis, Sonam Drogha, Phuntsok Dongdrup, Karma Lhamo,
Ojen Tsering, Tseyongjee, Dawa Khandro, L. Mullany, and
L. Weingrad. 2011. “Maternal and Child Health in Yushu,
Qinghai Province, China.” International Journal for Equity
in Health, http://www.equityhealthj.com/content/10/1/42,
accessed in 2012.
[12] World Health Organization, UNICEF. 2003. Global Strategy
for Infant and Young Child Feeding, Geneva, http://whqlibdoc.
who.int/publications/2003/9241562218.pdf.
[13] Donald Bundy, Carmen Burbano de Lara, Margaret Grosh,
Aulo Gelli, Matthew Jukes, Lesley Drake. 2010. “Rethinking
School Feeding: Social Safey Nets.” In Child Development
and the Education Sector, translated by Yang Yanyan and
Wang Le and reviewed by Cui Xin. Beijing: People’s Press.
[14] Changdu Health Bureau. 2011. Women and Children’s Health
Annual Data Analysis Report 2010 for Changdu Region,
Changdu.
[15] Chen, Chunming, Wu He, Yuying Wang, and Lina Deng.
2010. “Nutrition in Rapid Economic Development” and
“Nutrition Status in China under Global Financial Crisis.”
Report on Nutrition Policy Research, Nutrition Monitoring
Program Work Group, China Disease Control and Prevention
Center, Beijing.
[16] Hao, Zhirong. 2012. “Analysis on Rural Family Education in
China – Qualitative Study based on Ledu County in Qinghai
Province.” In Collection of Children’s Program Research
Outcomes, China Development Research Foundation.
[17] The World Bank. 2012. World Development Report 2012:
Gender Equality and Development. Beijing: Tsinghua
University Press.
[18] The Ministry of Health. 2007. Infant and Young Child
Feeding Strategy, http://www.gov.cn/fwxx/jk/2007-08/01/
content_703104.htm, accessed on March 16, 2013.
[19] The Ministry of Health, People’s Republic of China. 2012.
Report on the Nutrition Development of Children Aged
between 0 and 6 in China, http://www.moh.gov.cn/mohbgt/
s3582/201205/54990.shtml, accessed on February 22, 2013.
[20] Zhu, Ling. 2008. “Preventing Inter-generational Transmission
of Poverty at the Starting Point of Life.” China Demographic
Science, no.1: 30-36.