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."

On August 2, 2023, APARC Southeast Asia Program Director Donald Emmerson participated in a virtual discussion as part of a series on "Reinvigorating Commitment for Democratic Resilience and Good Governance," hosted by the Women in Foreign Policy, a program collaboration between the Foreign Policy Community of Indonesia (FPCI) and the U.S. Embassy in Jakarta.

The text of Emmerson's introductory remarks is included below. You can also watch Emmerson's additional comments throughout the discussion via the video recording embedded below following the text.

Remarks by Donald Emmerson 

In discussions of global affairs, including this one, it is always useful to distinguish between structure and agency: between embedded distributions of power that may be hard to change and the roles of individual and collective actors who can and may cause, alter, postpone, or prevent such change.  

Last year, in 2022, for the first time, our planet’s population reached 8 billion and our global economy exceeded 100 trillion US dollars in value.  But observers disagree about the current structure of world affairs.  

Two dichotomies are competing for attention. Some leaders prefer a vertical and mainly economic contrast between the developed “global North” and the less developed “global South.” Last month India’s prime minister Modi told the US Congress that “the global South is the way forward” and some say he hopes to lead the “global South” in reforming the world’s current geopolitical structure.  

U.S. President Biden has in the past offered a horizontal and partly ideological contrast between “Western democracy” and “Middle Eastern autocracy.” But his aversion to despotic rule in Russia and China suggests a broader rejection of “Eastern autocracy” even though he doesn’t use that term.

As for structure and agency, these two bits of economic and political geometry — North-South and West-East — are problematic. The world is not divided into four neatly circumscribed, internally homogenous, and traditionally identified blocs.  

Consider the association of the North and the West with economic growth and wealth, as opposed to the more impoverished South and East. The Gini index of inequality runs on a scale from zero, or complete equality, where everyone has the exact same income, to one hundred, where one person gets all of the income in the world. In recent decades, inequality among individuals within countries has increased slightly, but inequality between countries continues to fall and is now down to its lowest level in well over a century.  

One analyst concludes accordingly, in an article optimistically entitled “The Great Convergence” in the current issue of Foreign Affairs, that in global terms income is more equally distributed than it has been in more than a century. (See Branko Milanovic, “The Great Convergence,” Foreign Affairs, July-August 2023.)  

If this trend continues, it will become even harder to lump countries into blocs according to where they are on a map. Meanwhile, however, for multiple reasons including history, geography, demography, culture, and political economy, the five richest countries by GDP — the United States, China, Japan, Germany, and India, in that order — together account for more than half of Global GDP. Interestingly, China with 18 percent of the world economy is still behind the United States, which has 25 percent. But the structural lesson is that a stable future global order cannot be unipolar or bipolar, or reflect the primacy of any single region. It must instead be multiply, plurally — I’m tempted to say democratically — led.  

That morally and empirically constructive outcome is certainly endangered by structural differences. But by far the most imminent threat to the world stems from the expansionist agency of certain key leaders — Vladimir Putin in Ukraine, Xi Jinping potentially against Taiwan, and Donald Trump against democracy in America.

Let me end by focusing very briefly on Trump. A recent New York Times poll of registered voters shows 43 % supporting Biden and the exact same number — 43 percent — supporting Trump. Trump was impeached twice by one house of Congress, surviving only due to Republican objection in the other house, and has been indicted three separate times on criminal charges involving campaign bribery, security violation, and electoral subversion.  

The election won’t be held until November of next year, so it is far too early to predict an outcome.

But it is not too early to argue that success in multilaterally fashioning a suitably stable, democratic, and prosperous global order will require structural cooperation between regions led by honest leaders capable of constructive agency on behalf of justice, prosperity, and peace. 

 Additional comments by Emmerson

This commentary originally appeared in Nikkei Asia.

The Association of Southeast Asian Nations is due to hold its first joint naval exercise as a bloc next month.

This will be an important milestone at a time the group is facing daunting challenges to its interests and its diplomatic centrality in the Asia-Pacific region, including intensifying U.S.-China rivalry; an ongoing crisis in Myanmar that has divided ASEAN and left it looking feeble; the proliferation of alternative forums including AUKUS and the Quad; talk of a NATO office in Japan; and, of course, China's continued assertiveness in the South China Sea.

The upcoming drill, though, could have been a bolder, more assertive statement.

Indonesia, as ASEAN chair, initially proposed holding the exercise within the South China Sea. Unfortunately, due to Cambodian opposition, the exercise has been shifted to an area outside of China's expansive South China Sea claim. The Cambodians are said to have argued that the initial location of the drill, in the North Natuna Sea, would have unnecessarily upset China.

The decision to shift the exercise is a minor blow to ASEAN ambitions to bolster security cooperation but should not deter Indonesia and other member nations from making another run at a collective Southeast Asian naval drill in waters that fall within China's infamous "nine-dash line."

Such a drill would not only make sense from a policy and international law perspective but arguably reinforce one of the original intentions behind the founding of ASEAN in 1967, and address its current need to reaffirm the bloc's centrality.

ASEAN was established as a bulwark against communist expansionism and also to manage conflict and mistrust among neighboring Southeast Asian nations. The intention was to discourage great-power intervention and interference in the region.

The past 10 to 15 years, however, have seen significant intervention in the South China Sea, most notably by China, which continues to assert its expansive claim vigorously despite a ruling by a U.N.-backed tribunal that its nine-dash line claim has no basis in international law.

China's aggressiveness has prompted the U.S. and others to increase naval activity in the region to assert the right of navigation through what they maintain is an international waterway. Many ASEAN nations have complained about or felt uncomfortable with these activities, particularly those of China, but the bloc has struggled to back up its position with tangible action.

That is the beauty of an ASEAN naval exercise in the South China Sea. Properly designed and implemented, it would assert ASEAN centrality on a critical issue and put China on the back foot, without bringing in great power competition.

China would probably protest, but it is hard to imagine Beijing retaliating against a substantial group of Southeast Asian nations -- countries it is actively wooing -- acting together. The U.S. probably would welcome ASEAN's action, which would advance the cause of treating the area as international waters without its own involvement.

To be successful, the exercise would need to include only ASEAN members, as any outside participation would undermine the whole point. As Indonesia originally proposed, it should also be run as a humanitarian relief exercise rather than anything more overtly "military."

Such an exercise would not resolve South China Sea territorial claims nor prevent China from continuing to assert its claims. Nor would it end the bloc's divisions over Myanmar or other matters. It would, however, boost ASEAN's diminished credibility, while pushing back on unjustified Chinese claims in a manner that Beijing would not easily be able to counter or blame on the U.S.

If the initial exercise were carried off successfully, it could lead to regular drills, potentially reducing the perceived need in Washington and other capitals to assert freedom of navigation rights in the South China Sea themselves. In that sense, it could reduce great-power tension and "interference" in the region.

The big question, of course, is how Indonesia and other proponents can overcome the objections of Cambodia, and possibly other member states.

Perhaps further discussions within the bloc could produce a plan that all members could accept. In the more likely case that divisions persist, then Indonesia, as ASEAN chair, could organize a naval exercise open to any bloc member willing to participate.

This presumably would include Singapore, Malaysia, the Philippines, Vietnam and ideally Thailand, at least.

Such a "minilateral" approach would be unusual but feasible, particularly if no external powers are involved. After all, Thailand recently broke with established ASEAN consensus to host a minilateral meeting on Myanmar that upset some of its fellow member states.

If need be, countries participating in a South China Sea drill could call it an "informal" ASEAN exercise to get around the lack of consensus. If the six mentioned countries all participated, it would still send a strong signal that ASEAN can, formally or informally, still act on critical issues.

ASEAN has a chance to take a significant step that would be in line with its original purpose and that would do much to bolster its standing, and possibly even reduce great power tension in the South China Sea. Indonesia and other like-minded ASEAN members should seize the chance and make it happen, especially since Indonesia is due to pass on the role of bloc chair to Laos, whose government is particularly susceptible to Chinese influence, later this year.

This commentary was first published by The Diplomat.

Indonesia’s $20 billion Just Energy Transition Partnership (JETP), announced last November by U.S. President Biden, Indonesian President Joko Widodo, and Japanese Prime Minister Kishida Fumio, is reaching an early critical juncture. The stakes involved are high, encompassing climate change, economics, U.S.-Indonesian relations, and geopolitics.

Under the Partnership, an International Partners Group (IPG), made up of the G-7, Norway, and Denmark and led by the United States and Japan, promised to mobilize $10 billion in financing, while a private sector alliance committed an equal amount. Indonesia agreed to accelerate the retirement of coal-fired power plants and promote renewable energy, setting targets of capping emissions from its power sector, making that sector carbon neutral by 2050, and tripling the share of renewable energy in the power mix by 2030.

If the partnership succeeds, Indonesia – one of the world’s largest greenhouse gas emitters – will be on a path toward significantly reduced emissions. Moreover, success will demonstrate that the JETP model is viable, encouraging similar partnerships elsewhere. Failure would undermine the JETP concept and discourage efforts by other developing countries.

For Indonesia, JETP provides an opportunity not only to shift away from dirty coal power but also to enhance its attractiveness as an investment destination. Although Coordinating Minister Luhut Panjaitan, who has been overseeing its implementation, has sought to put all the pressure on the IPG, saying “we don’t lose anything if the deal doesn’t materialize,” a failed deal would mean Indonesia leaving billions of dollars on the table, and would reinforce perceptions that it is a difficult place to do business.

The stakes for the United States are equally high. Washington led the negotiations and will get much of the credit or blame for JETP’s success or failure. Also, the recent U.S. track record on economic issues in the Asia-Pacific region has been poor, the result of its withdrawal from the Trans-Pacific Partnership, avoidance of other trade agreements, and failure to deliver on its “quality infrastructure” initiatives. The United States is widely viewed as losing economic influence in the region to China. The Indonesia JETP deal is a chance for Washington to demonstrate that it can deliver and thereby boost its geostrategic position. Failure would do just the opposite.

Finally, JETP offers a means to improve U.S.-Indonesian relations. Indonesia is important – the world’s third-largest democracy, the biggest Muslim-majority nation, a rising economic power, and a leader of the Association of Southeast Asian Nations (ASEAN). While security ties have improved, economic relations have stagnated, the Indonesian public remains cool toward the United States, and Washington worries about Jakarta’s growing ties with China, which provides it with needed infrastructure financing.

JETP already is facing significant challenges. It was always going to be difficult for Indonesia to shift away from coal, an industry that has produced powerful conglomerates and employs around 250,000 people. The country has a surplus of power capacity in key regions and a relatively new fleet of coal plants, making early retirement costly. Moreover, the current regulatory environment, including Jakarta’s local content requirement, makes investing in renewable energy unattractive. There are other challenges, but discussions with experts suggest most can be overcome with sufficient will and financing.

Therein lies the bigger, more immediate problem. Following an April visit to Washington, Indonesian officials complained that the IPG was asking Jakarta to take difficult steps without doing its part. Minister Luhut told the press that Washington had not “shown” them any money or clarified how Indonesia can access JETP funds. He also emphasized that the money needed to come on concessional terms. An Indonesian official involved in JETP said privately that they are informed that grants would make up only a small fraction of the $20 billion in financing and that only one-third of the money would consist of truly concessional loans. “The [financing] package,” the official added, “is not aligned with the spirit of the partnership and ambitious transition required in JETP, which without real financial support will add significant financial burden to Jakarta.”

Other conversations suggest increasing doubt in Jakarta about whether the money will materialize, along with what one Indonesian expert called a growing worry that JETP will fail before it gets started. U.S. officials say it will be “bankable” projects identified in the JETP investment plan, expected next month, that should trigger the flow of money. They insist the financing will be there.

Given the stakes, Jakarta and Washington need to redouble efforts to move the partnership forward. For Indonesia, that means completing an investment plan with bankable projects, offering regulatory reform to make renewable energy investments more attractive, and addressing the contracts behind the current energy surplus. It also will mean accepting less concessional financing than it wants. For Washington, it involves quickly demonstrating that it and its IPG partners will meet their financing commitment with reasonably concessional terms and clarify the mechanism for accessing the JETP funds.

Time is of the essence. To bolster lagging confidence, the parties need to announce several pilot projects soon and move vigorously to implement them. The opportunity presented by the JETP initiative is too good to miss, and the cost of failure is high.