On October 18, as part of its autumn 2023 seminar series on APEC in advance of the organization's meeting in San Francisco in November, Shorenstein APARC and its Asia Health Policy Program (AHPP) presented the series' second event, Asia-Pacific Digital Health Innovation: Technology, Trust, and the Role of APEC. The featured panelists were Kiran Gopal Vaska, Director of the National Health Authority of India, and CK Cheruvettolil, the Senior Strategy Officer, Digital Health and Artificial Intelligence, at the Bill & Melinda Gates Foundation. Siyan Yi, the Director of the Integrated Research Program at the National University of Singapore and a former AHPP fellow, moderated the conversation.

While India is not an APEC member, Indian initiatives are examples of leveraging technology to better the health of the most vulnerable citizens in low- and middle-income countries (LMICs). Kiran Gopal Vaska gave an overview of the Ayushman Bharat Digital Mission (ABDM), India's latest health initiative that focuses on the interoperability of health records, services, and health claims. He stressed that ABDM was built on previous digital infrastructure, like Aadhaar, the national digital identity system, and Digilocker, a digital storage scheme for citizens' health and other records.

The approach India has taken is for the government to build the rails—the infrastructure of the system—and create a space where the private sector can develop applications integrated with that space through application programming interfaces (APIs), avoiding the siloing that can hamper the interoperability of data.

Regarding health data, privacy is a crucial concern at the patient level. ABDM addresses this concern through the use of a consent artifact. Individuals decide whether hospitals or other medical service providers have access to their data, and this access has levels of granularity: you can share specific portions of 7 different data types, like immunizations or prescriptions. You can limit that sharing to a particular period, like one day.

Also participating on the panel was CK Cheruvettolil, who discussed strategies by the Bill & Melinda Gates Foundation in leveraging the power of mobile phones to augment the work of Accredited Social Health Activists (ASHAs), the more than one million female frontline health workers in India. ASHAs can use mobile phone cameras, sensors, and streaming data to better care for low-birth-weight babies and other patients. 

He explained the critical role of taking local context into account when developing software by using the example of pregnant Indian women in their third trimesters. The custom for Indian mothers, especially in rural areas, is for the child to be born in the maternal grandparents' home. If software were to store only the mother's address, healthcare workers in the grandparents' jurisdiction would not know that a pregnant woman in the critical third trimester would soon be giving birth at a local address.

Kiran Gopal Vaska noted that India had solved the technological issues, and now the task was to push for adoption. He emphasized that the technologies underlying India's digital health stack were created as public goods for the world, and for LMICs to support each other in advancing digital health technologies, the key was interoperability, "using standards that are accessible and acceptable worldwide."

This story was updated on September 18, 2023, to reflect the passing of Victor Fuchs.

It is hardly news that America’s health care system is complicated, expensive, and, in many ways, dysfunctional and that the nation’s health care outcomes are falling behind those of other, even sometimes poorer, countries. The problems of rising costs and disparities in access and outcomes were already well established in 1974, when Victor Fuchs, the late Henry J. Kaiser, Jr., Professor of Economics and of Health Research and Policy at Stanford, first published his seminal book Who Shall Live? Health, Economics and Social Choice. In what turned out to be the first edition of the book, Fuchs applied fundamental concepts from economic theory to health and medical care in an innovative manner that hadn't been attempted previously, presenting an economic framework for addressing health and medical care challenges and emphasizing the importance of choice at both individual and societal levels. The publication became a classic introduction to health economics and is recognized for pioneering the field.

Now a third edition of Who Shall Live? has been released by World Scientific Publishing, co-authored by Karen Eggleston, director of Shorenstein APARC’s Asia Health Policy Program. This edition adds supplemental research and an all-new section that focuses on the decade 2012–21, specifically looking at the Affordable Care Act, the COVID-19 pandemic, the intersection of health and politics, and the state of expenditures and outcomes during that period.

Eggleston was honored to be able to work with Fuchs, who had also been a senior fellow emeritus at the Freeman Spogli Institute for International Studies and the Stanford Institute for Economic Policy Research, but noted that “it was a little depressing to hear him conclude that the pandemic would not be the 'wake-up call’ for systemic reforms that he has spent a lifetime showing the United States needs.” Fuchs passed away peacefully in his longtime home on Stanford’s campus on September 16, 2023. He was 99.

Part of the story of U.S. health care is its poor showing compared to other, often less-affluent nations. Japan is one of the comparison countries in the updated section on the last decade; in one example, Eggleston describes, “between 2012 and 2019 (pre-pandemic), life expectancy at birth did not increase at all in the United States, while it increased 0.18 years per annum in Japan, and 0.16 years per annum across 10 other high-spending OECD countries.” This is despite the fact that “in 2019, Japan spent only 63% of what the United States spends on healthcare (as a share of GDP)… Why can’t we do better for Americans?” 

This question is precisely the one that Who Shall Live? aims to answer—that the state of any health care system is a result of “the necessity of choice at both the individual and social levels.” To shrink the costs of health care in the United States and improve outcomes, different choices have to be made—by patients (in their personal lifestyles and behavior), by physicians, by hospitals, and by the U.S. government.

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A Shifting Civil Conflict

Nyantha described the evolution of the anti-coup movement in Myanmar from its beginnings with protests and civil disobedience campaigns by government workers and civil servants to its current state of armed resistance movement aimed at bringing down the military regime. Ethnic Armed Organizations (EAOs) have played a pivotal role in this shift. These non-state actors have fought the Myanmar military for decades in the borderlands and hold parts of the country under de facto control, sheltering and training tens of thousands of young people.

These resistance groups now present a powerful front of grassroots-level insurgency that is hampering operations by the coup regime. In this collection of self-organized groups, some are working with the National Unity Government (NUG) shadow administration, others with more decentralized networks, but all share the conviction that armed struggle is the only option for dealing with the military regime.

The power dynamic between the military and anti-regime resistance forces is now existential for both sides. “We are looking at what will most likely be a protracted civil conflict in Myanmar,” says Nyantha.

What are the paths toward a better future for Myanmar? One possibility is a shift in the military’s calculus, though it would necessitate a leadership change. Another possibility, according to Nyantha, is that the array of opposition actors can come together and use multilateral platforms to facilitate unprecedented forms of cooperation beyond resistance against the military to establish areas of territorial control and self-governance. “If they can emerge from this process with a new political vision and a roadmap for a more tolerant and inclusive Myanmar, then there is a chance the balance may tip against the military.”

These platforms include the National Unity Consultative Council (NUCC), which includes representatives from multiple opposition groups. Depending on how dialogues within the NUCC continue, it could generate a new political dynamic in the country and lay the groundwork for a future federal democratic union, notes Nyantha.

Historical Grievances, Future Visions

But there remains a lot of work to do to build trust among Myanmar’s traditionally fractious ethnic groups, Ambassador Marciel stresses. This mistrust has historical roots in decades of political disunity among Myanmar’s ethnic minorities amidst struggles for autonomy and self-determination, and in their longstanding grievances toward the state that has privileged the majority Burmans (also known as Bamar). Thus, possibly the biggest weakness of the resistance movement is the lack of a unified vision for establishing civilian rule. “I do think that it is hugely important to bring about more unity to the movement that is resisting the military regime,” says Marciel.

The international community should better understand the complexity of the civil conflict in Myanmar and recognize that the spontaneous revolt underway is not only a resistance front against the military but also a movement demanding dramatic social and political change, Marciel emphasizes.

He, therefore, cautions that the traditional tools of conventional diplomatic thinking – ceasefire, peaceful negotiations, and dialogue — do not currently apply to Myanmar. “At this point, there is no realistic scenario of dialogue leading to some compromise deal. As long as the military is in power, Myanmar is not going to enjoy peace or stability.” The people of Myanmar have suffered for far too long at the hands of the military, and the resistance forces are not interested in a compromise deal that would allow the military to maintain substantial political power, Marciel says. At the same time, the military is also not interested in negotiating.

According to Marciel, the international community should focus on supporting the resistance movement efforts. He also expressed this point in a recent interview with The Irrawaddy. “[T]he best possible scenario is for the military to face so much pressure that they then begin to look for a way out […] I think that maximum pressure on the military, both internally and externally, whether it’s by sanctions or other means, is the best chance of achieving progress, though it won’t be easy.”

A Deadly Syndemic

Even before the coup, Myanmar had one of the world’s weakest health systems and one of the least prepared for addressing epidemics and pandemics, according to the 2019 Global Heath Security Index. The devastating effects of the coup have coincided with the COVID-19 pandemic, combining into a perfect storm that has brought the country’s already-fragile health system to collapse.

The coup and the post-coup conflicts interact with the pandemic and Myanmar’s fragmented health system in ways that resemble a syndemic, says Phyu Phyu Thin Zaw, a medical doctor, epidemiologist, and health systems researcher now based at the University of Hong Kong’s School of Public Health. The term syndemic refers to the synergistic nature of health and social problems affecting vulnerable communities and contributing to an excess disease burden. It helps explain the dire crises gripping Myanmar’s health system, explains Dr. Thin Zaw.

Thin Zaw, a former visiting scholar at APARC, spoke at a webinar hosted by the Asia Health Policy Program about the impacts of the devastation caused by the coup and the COVID-19 pandemic on Myanmar’s health system and the current opportunities and challenges for response and recovery. She was joined by Nay-Lin Tun, a medical doctor who manages programs that help vulnerable communities in remote and conflict-affected areas of Myanmar to get access to health services.

Since the coup, hundreds of medical personnel and health care workers have been dismissed and subject to violent attacks. Many have escaped to areas under the control of anti-junta forces, leading to a severe “brain drain” or rather “brain hemorrhage” in the health system, Thin Zaw notes. When the third wave of the coronavirus struck Myanmar in July 2021, it hit like a tsunami. Immunization plans were severely interrupted, no quarantine or contact tracing measures were taken, and with shortages of health workers, medicine, and equipment, the health system was soon overwhelmed, with thousands of infections and rising deaths.

“To fight a pandemic, collective action is needed. Instead, Myanmar has faced a collective trauma,” says Thin Zaw. “The coup destroyed the reciprocal trust both horizontally among people and vertically between people and the government.”

Challenges for Humanitarian Response

Myanmar needs humanitarian assistance in every area, but grueling challenges hamper humanitarian relief delivery. International aid groups grapple with shuttered access, high-cost and high-risk operations, and ethical and political dilemmas: Should they stay or exit? Through which channels should they deliver aid? How can they advocate and work with the military junta? How should their money be spent under the military regime?

Dr. Tun, providing a grassroots medical humanitarian perspective on what is happening in Myanmar, described the multiple problems facing providers and patients on the ground. These include a severe shortage of health workers on the frontline, difficulties getting patients to hospitals, lack of essential medical supplies and equipment, COVID-19 infections, and overall increased mortality and morbidity among IDPs. He presented the results of a mixed-methods survey of health care workers conducted in non-military-controlled areas and conveyed their urgent requests for help. 

A Way Forward

With Myanmar’s health system in collapse, this is a time to focus on strengthening primary health care and leveraging the silver lining of the post-coup softening of ethnic tensions to build a federal health education system for inclusiveness, said Thin Zaw. She pointed to the collaboration between the NUG and EAOs-controlled healthcare groups as an encouraging step towards creating a federal health system.

She urged international actors to be realistic about the limits of their influence over the military junta and to create flexible and politically sensitive aid programs with contingency plans. Yet international organizations must continue all efforts to support the delivery of critical services to the people of Myanmar, especially in areas such as food security, emergency health, and COVID-19 response, she said. “Please don’t forget the people of my country,” she pleaded.