As incomes rise around the world, health experts expect a more troubling figure to increase as well: the number of diabetics in developing countries.

In China and India – two of the world’s most populous nations with fast-paced economies – the prevalence of diabetes is expected to double by 2025. Between 15 and 20 percent of their adult population will develop the disease as household budgets increase, diets change to include more calories and new health problems emerge.

But China, India and other developing countries are not fully prepared to deal with the rising trend of diabetes. And a growing number of diabetics aren’t getting the care they need to prevent serious complications, Stanford researchers say.

Even with insurance, many diabetics don’t have essential medications that could help them manage their conditions. In many cases, people are spending a great deal of their household incomes to pay for their treatment, said Jeremy Goldhaber-Fiebert, an assistant professor of medicine who led the research team.

“Public and private health insurance programs aren’t providing sufficient protection for diabetics in many developing countries,” said Goldhaber-Fiebert, a faculty member at Stanford Health Policy at the university’s Freeman Spogli Institute for International Studies. “People with insurance aren’t doing markedly better than those who don’t have it. Health insurance and health systems need to be re-oriented to better address chronic diseases like diabetes.”

Findings from the study are online and will be published in the Jan. 24 edition of Diabetes Care, the journal of the American Diabetes Association. The journal article was co-authored by Jay Bhattacharya, an associate professor of medicine and Stanford Health Policy faculty member; and Crystal Smith-Spangler, an instructor at Stanford’s Department of Medicine and an investigator at the Palo Alto VA Health Care System.

Failure to adequately manage diabetes will lead to more severe health problems like blindness, heart disease and kidney failure. It also harms the otherwise healthy, Goldhaber-Fiebert said.

Diabetes often strikes people at an age when they’re taking care of children and elderly parents. To sideline these primary caretakers as dependants will lead to a heavy burden for communities and create an obstacle for economic growth, he added.

Using responses to a global survey conducted by the World Health Organization in 2002 and 2003, Goldhaber-Fiebert and his colleagues examined data from 35 low- and middle-income countries in Asia, Latin America, Africa and Eastern Europe to determine whether diabetics with insurance were more likely to have medication than those without insurance.

They also wanted to know whether insured diabetics have a lower risk of “catastrophic medical spending,” a term the researchers define as spending more than 25 percent of a household income on medical care.

“Surprisingly, diabetics with insurance were no more likely to have the medications they need than uninsured diabetics,” Goldhaber-Fiebert said. “They were also no less likely to suffer catastrophic medical spending.”

There are many reasons why health insurance may not protect diabetics in developing countries against high out-of-pocket spending. In some cases, there’s a lack of sufficient medication – such as insulin – that regulate glucose levels. Without those drugs, there’s a greater risk of complications that often lead to more hospitalizations and more expenses.

In other cases, co-payments and deductibles are too high. Sometimes, drugs and medical services to prevent diabetes complications are not covered. And doctors and hospitals don’t always accept insurance.

“Better policies are needed to provide sufficient protection and care for diabetics in the developing world,” Goldhaber-Fiebert said.

Without medications to manage diabetes and prevent secondary complications, the condition will worsen and the burden of catastrophic spending will increase, he said.

“It’s important to get ahead of the curve and prepare so there’s an infrastructure in place to deal with these health and cost issues,” he said.

While preventing diabetes in the first place would be ideal, programs and policies must be established to care for the many cases that will surely continue to exist.

“There isn’t a single country that’s managed to entirely arrest or reverse the trend of diabetes,” he said. “Programs that focus on primary prevention are extremely important, but the reality is that the developing world faces hundreds of millions of diabetes cases that are unlikely to all be prevented.”

More than 500,000 people live in Mathare, the second-largest collection of slums in Nairobi, Kenya. Crime and disease ravage the population, and shanties have no electricity or running water. But there’s one piece of technology that everyone seems to have, one which promises to bring much-needed improvements: the cell phone.

Cell phones are central to two of the eight most recent Global Underdevelopment Action Fund projects funded by the Freeman Spogli Institute for International Studies. Both projects will be led by Joshua Cohen, a professor of political science, philosophy and law and the Marta Sutton Weeks Professor of Ethics in Society.

The first of Cohen’s projects will examine whether texting private and accurate health advice will increase awareness of risky sexual behavior among Mathare’s younger residents who face high rates of pregnancy and sexually transmitted diseases.

Cohen's second project involves teaching women to use mobile technology to meet up with larger groups while traveling at night, which Cohen believes can led to a decrease in the number of assaults, muggings and rapes. Eventually, the hope is that the program can be taken over by Kenya’s police and expanded.

Cell phone charging station in Mathare

Six other projects are receiving support from the third round of Global Underdevelopment Action Fund awards, amounting to a total of $265,000.

The funds will enable multidisciplinary teams led by Stanford faculty from across the university to perform policy-relevant research focused on global underdevelopment challenges.

The funded projects will have real world impact. They will help target tuberculosis, which kills more than 1 million people a year and hinders economic development in the hardest-hit regions, like parts of India. They evaluate the amount of resources necessary to improve test scores and lower anemia rates among China’s rural schoolchildren. They ensure that health care is accessible to people in the Arab world where countries are undergoing political transitions. And they evaluate the challenges and benefits of bringing solar power to areas in Africa where electricity is a rare commodity.

As varied as the eight projects are, each will train Stanford undergraduate or graduate students, stressing the importance that Stanford and FSI place on training the next generation of researchers and policy influencers.

The projects were selected by a faculty committee chaired by Stephen D. Krasner, FSI’s deputy director and the Graham H. Stuart Professor of International Relations.

The Action Fund is supported by FSI donors, matching funds from the Office of the President and FSI. The fund grew out of the institute’s 2010 conference on Technology, Governance, and Global Development. This year’s follow-up conference further showcased FSI’s commitment to challenges posed by global underdevelopment with a focus on food security and health.

The award-winning projects and their principal investigators are:

• Texting for Sexual Health: Effects of Information Provision and Common Knowledge on Health-Seeking Behavior in Kenya
  Joshua Cohen
  In hopes of increasing awareness that could minimize sexual health risks, the team will promote a mobile health counseling service, which will enable young people in Nairobi’s Mathare slums to receive private and reliable answers from health counselors through text messaging.
• Can Mobile Phones Coordinate Community Action to Improve Women’s Safety in Slums?
  Joshua Cohen
  The program uses mobile technology to measure whether the number of assaults on women will decrease if they travel in groups. The project will evaluate whether this “safety in numbers” program can be taken over by Kenyan police.

• Crime, Violence and Governance in Latin America: Sharing Data and Building a Web-Based Research Network to Expand Knowledge
  Mariano-Florentino Cuéllar
  This project will build a systematically organized repository of research on crime, violence and citizen security in Latin America.
• Tuberculosis Control and its Benefits to the Rural Poor
  Jeremy Goldhaber-Fiebert
  This study will determine the impact of improved TB control effects in India, which accounts for 20 percent of global TB incidence, and project economic outcomes from India’s TB epidemic over the next decade.
• Paying for Performance to Improve Health in Rural China: Does Resource Scarcity Breed Innovation in Service Delivery?
  Grant Miller
  This study will evaluate whether large subsidies are necessary for improving social situations like lowering anemia rates or improving test scores.
• Health and Political Reform in the Arab World
  Paul H. Wise
  Partnering with The Lancet journal and the American University of Beirut, the team will produce a series of articles on war, social change and health in the Arab world with a goal of improving health care in countries undergoing political transition.
• Solar Lighting and Phone Charging in East Africa: Understanding Adoption, Business Models and Development Outcomes
  Frank Wolak
  This project will analyze new solar businesses in East Africa. Electricity is central to industry, health services and education, yet 1.5 billion people worldwide lack access. Recently, low-power solar energy sources in homes have appeared as viable options.
• Understanding the Current Status of Medical Technology in Rural China
  Paul Yock
  This study will evaluate the use of medical technology in rural China in order to establish a baseline for future work and establish partnerships. The long-term goal is an analytical framework within which to understand the role of medical technology in Chinese health care.

Between 2008 and 2009, approximately 25 new private engineering colleges opened in India every week—adding 2500 schools in only two years. Engineering education is also on the rise in the other so-called BRIC countries (Brazil, Russia, and China). But does quantity guarantee quality? And what should government policymakers keep in mind to ensure that their higher education investments pay off?

Rafiq Dossani, a senior research scholar at the Shorenstein Asia-Pacific Research Center, recently collaborated with Stanford professor of education Martin Carnoy and a team of scholars in Russia, China, and India on a leading-edge comparative study of higher education systems in BRIC countries. Carnoy led the project, which focused on engineering education, and he, Dossani, and other researchers are currently writing a book coming out in 2012. Dossani speaks here about the project.

What is unique to the approach that you have taken with this study compared to anything similar previously conducted?

This is the first systematic study based on a large data collection. Over 7,000 students were surveyed in China and India respectively, and 2,300 students were surveyed in Russia. Brazil regularly collects detailed data on a very large nationwide sample of university students, and we have used this in our study. We also surveyed over 100 educational institutions, including several dozen face-to-face interviews with trustees, heads of institutions, heads of departments, faculty, administrators, and students.

We focus on engineering education in our study because it is the field that attracts the largest number of students. For example, in China, about 63% of students in 2009, or about 1.8 million students, entered through the science track, which is the route to an engineering degree. In India, 1.4 million freshmen engineering students were enrolled in 2011, which is over 40% of the total number of freshmen.

In our study, we ask how governance and finance affect outcomes in higher education. Every country’s educational system shares certain objectives: quality, access, and equity. What has not been studied for the BRIC countries is whether the governance and finance of higher education is consistent with some of these objectives but not others, and how this impacts the shape and effectiveness of the higher education system. The choice of governance and finance are themselves outcomes of the institutional settings in each country. For example, in India, the dramatic transfer of political power in the last two decades from the national government to the provinces has been the key driver of change.

As a result of this shift in political power, the states took charge of higher education and focused on increasing access and equity as their political goals. Given the extreme shortage of funds, they contracted out the actual provision of education to the private sector on attractive terms. The private sector responded briskly. Of the 1.4 million freshmen enrollees in engineering studies in 2011, 98% were enrolled in private institutions, compared with less than 5% in 1990. The rate of growth was so high that in just two years, 2008 and 2009, 2500 new engineering colleges opened their doors. That works out to about five new colleges for each working day!

There were upsides and downsides to this growth. On the positive side, the state offered attractive financial terms for new institutions located in underprivileged areas and mandated that about 50% of seats be reserved for underprivileged students (mostly identified by caste). It also kept tuition fees for the reserved seats very low at about $500 per student per year and allowed the colleges to recover costs and margins by charging a higher fee for the rest. The result was that growth has been geographically spread and access by underprivileged students is high—in our study, 55% of the students came from underprivileged categories.

The downside is that quality remains elusive. Although this does not show up in job placement rates due to pent-up demand, comparisons with the other BRIC countries suggest that the quality is low. The reason is that private providers, for the moment, find it more profitable to provide minimal infrastructure and employ inadequate faculty than to invest in building up quality for the long-term. In fact, given that the investment in long-term quality is likely to be unaffordable, one of our conclusions is that we question the sustainability of the Indian governance and finance model vis-à-vis the other countries in our study, particularly China, where the central government is taking an activist approach in trying to increase quality, at least in the elite universities.

How do your findings in India’s higher education system for engineering compare to the other BRIC countries, especially China as the study’s other Asian country?

In terms of sheer growth and the number of engineering freshmen, China exceeds India. The cost of education is lower in India. In terms of quality, China, Brazil, and Russia, do better. Part of the reason is a superior entering cohort in the case of China and Russia. But the main reason appears to be that governance in the other BRIC countries is more faculty-driven than driven by profit-oriented trustees. We found that the former model is more likely to deliver quality. In the case of China, for example, academic departments determine courses, course content, and the types of disciplines available, whereas in India, trustees make such choices, with poorer quality outcomes.

You have previously said that India’s higher education system is very politicized—how did it come to be this way?

The politicization began at the country’s independence in 1947. Prior to independence, higher education was managed by provinces to produce graduates from the upper classes who would join the colonial civil service. After independence, the state governments faced new demands for higher education from the middle classes. Since these were also important voting classes, the state responded by setting up a large number of public universities. The state controlled all aspects of the university to ensure that their priorities were met, in terms of location, fees, and personnel hired. For example, the state government was represented in the senate of every university and public college. Every senior-level hire needed to be approved by the state government. State government nominees on the senate also reviewed textbook selections and disciplinary choices.

As may be imagined, educational quality suffered and continues to do so in the public colleges. In the mid-1990s, the states faced demands from new voter categories, particularly lower-caste groups. These were earlier excluded from political power but acquired power in the federalization of politics that took place from 1990 onwards. This time around, though, the states decided to subcontract the work to the private sector rather than set up public colleges. This was largely a matter of cost management—the state thought that the private sector would respond to the incentive of providing technical education to those willing to pay full-cost, and invest the needed capital. This would free up the state’s capital for other demands, including for education, such as for primary and secondary education. To ensure that the lower-caste groups were part of the expansion, the state mandated quotas and subsidized fees. In the name of preserving quality—although, in fact, it preserves quality only at low levels—the state continued to exercise other controls. For example, it imposes common curricula and assessment, and, in most cases, certifies a private college only if it is part of a publicly owned university system.

The state’s policies also led to a shift in the profile of the graduates towards technical and professional education, since these were the fields in which the private sector was willing to establish new institutions. This was greatly stimulated by rising income payoffs to higher education engineering and business training. Private colleges account for 60% of the growth in educational provision between 1995 and 2011, and almost all of that growth is in engineering, management, and other professional fields. The value of this is debatable: it reflects the “market” but, deprived of state support, some fields that may be considered to be socially valuable, such as the liberal arts, are in steep decline.

Has the state of higher education in BRIC countries, such as India, led students to seek education opportunities abroad?

In China and India, these are important reasons for student migration to the West. For example, 500,000 students enroll as freshmen overseas from India alone every year. They come mostly from elite families, since the costs of an overseas education are very high.

What long-term policy changes are you hoping to influence through this study and your forthcoming book?

First, we show that the evolution of higher education in the BRICs can be explained by the role of the state (the government sector) and the policy choices it makes in governance and finance.

Second, we show that private provision can substitute for public provision, but with certain disadvantages in terms of quality and educational diversity. In this context, we show that state policy can still influence some outcomes positively, such as access, equity, and cost-control. However, the long-term implications for quality are much more negative through such a model. 

Third, we show that the provincial governance of education offers certain advantages and disadvantages over national regulation. This is a hotly debated topic in China and India. In India, the national regulators seek greater control out of concern about the implications of too politicized an environment created by the states and the poor quality emerging from private colleges. However, we argue that there may be downsides to centralized control, as was witnessed in an earlier period (during the tenure of Indira Gandhi).

Finally, we make the case that the current ”trend” among governments in developing countries of focusing on the creation of a few world-class universities can succeed in the limited sense of creating a few high-quality teaching and research institutions. However, it comes at a very high cost and in no sense guarantees a trickle-down of quality to the remaining institutions. This is particularly the case in the current model in China and Russia, where the emphasis on world-class universities is greatest and these high-cost elite institutions are given increasing funding per student. At the same time, mass universities absorb increasing numbers of students at low and possibly declining per-student funding.

In conjunction with the Stanford Center for International Development (SCID), REAP-Stanford Director Scott Rozelle chaired a conference on December 6, 2011 that addressed continued growth in China. Titled, “Growth without Equity?” the day-long conference brought together leading minds in academia, government, and the private sector to discuss the nature and severity of China’s human capital gap and its implications for the country’s continued growth. Participants discussed current inequities in China and the potential for the country to fall into a “middle income trap.” The conference also included panels of experts on Korea, Mexico and Brazil that explored lessons from those countries’ development that could inform China’s future growth policies.  

Click here for event agenda and selected presentations from the event.