This paper reviews the status of health education in urban schools in three cities in Liaoning province, China. The cities represent the upper, middle and lower levels of city economy based on the GDP per person within the province. A self-administered questionnaire was provided to 500 primary and secondary schools and 436 questionnaires (87.2%) were returned completed. The questionnaire assessed health education offerings in the schools, permitting the comparison of similarities and differences in school practices, and the identification of obstacles that prevent schools becoming health promoting. The analysis revealed that 0.7% of schools fulfilled criteria for good status of health education. The negative attitudes of school management, teachers and pupils towards health education, as well as the lack of in-service training for staff, were perceived as key obstacles to school health education. Few provincial and school-based policies mentioned pupil involvement in health policy development and only a small number of schools acknowledged the need to improve community and parental involvement. In this paper we discuss the challenges facing provincial education and health authorities, and make recommendations about how to assist Chinese schools to develop and implement high quality health education initiatives.