The Asian Trends Monitoring Bulletin is a project sponsored by the Rockefeller Foundation, New York, the Centre for Strategic Futures, Singapore, and the Lee Kuan Yew School of Public Policy, National University of Singapore. The Lee Kuan Yew School of Public Policy gratefully acknowledges the financial assistance of the Rockefeller Foundation and the Centre for Strategic Futures, Singapore. The Asian Trends Monitoring Bulletin focuses on three areas of strategic concern to Asia’s well-being and future development: 1) Trade and investment facilitation; 2) Health systems; and 3) Energy security. The Asian Trends Monitoring Bulletins are designed to encourage dialogue and debate about critical issues that affect Asia’s ability to reduce poverty and increase awareness of the implications for pro-poor policy and policy development. Disclaimer The opinions expressed in the Asian Trends Monitoring Bulletin are those of the analysts and do not necessarily reflect those of the sponsor organisations. Frequency The Asian Trends Monitoring Bulletin will be produced ten times a year. Subscription Subscription is free. To register, please contact Chris Koh at +65 6516 8004 or chris.k@nus. edu.sg. This publication is also available at www.asiantrendsmonitoring.com Production Manager, Production & Research Dissemination Chris Koh Editorial Trade & Investment Facilitation Darryl S.L Jarvis Leong Ching Health Systems Phua Kai Hong Nicola Pocock Energy Security Benjamin K. Sovacool Anthony D’Agostino Contact details of the editorial team are available on the last page of this publication. Please contact us if you would like a referenced version of the Bulletin. Image credits, with thanks Image on page 3 is copyrighted by c.ronnie.* Image on page 7 is copyrighted by Jed Villa Bali.* Image on page 8 is copyrighted by World Bank Photo Collection.* Image on page 9 is copyrighted by IRRI Images.* Image on page 14 is copyrighted by IRIN Photos.* Image on page 15 is copyrighted by Anthony D' Agostino. Image on page 17 is copyrighted by j. reed.* Image on page 23 is copyrighted by local surfer.* These images can be found on www.flickr.com
Permission is granted to use portions of this work copyrighted by the Lee Kuan Yew School of Public Policy. Please acknowledge the source and send a copy of the book, periodical or electronic document in which the material appears to either email@example.com or Chris Koh Lee Kuan Yew School of Public Policy 469C Bukit Timah Toad Singapore 259772
CONTENTS AT A GLANCE
THE ROLE OF ICT AND HOW IT HELPS THE POOR
BRIDGING THE ASIAN DIGITAL DIVIDE
EMPOWERING THE POOR AGAINST CLIMATE CHANGE
ICT LEADS TO BETTER PUBLIC HEALTH?
EMERGING TRENDS, IMMINENT THREATS AND ONGOING CHALLENGES
1 | AT A GLANCE
A national action month for HIV / AIDs prevention and control initiated by Vietnam’s MOH and the Thai Nguyen Provincial People’s Committee ran from 10 November to 10 December 2010. Vietnam has seen a sharp rise in infection rates due to unsafe sex in recent years. The 61st meeting of the WHO’s Regional Committee for the Western Pacific took place on 11-15 October 2010 in Malaysia. Ministers discussed the need to improve health system resilience during natural disasters, prevention of dengue fever and women’s health. ASEAN+3 (Japan, China and South Korea) agreed to set up a permanent rice reserve system amongst the 13 countries in a move to boost food security in the region at the ASEAN summit held 28-30 October 2010. Malaysian PM Najib announced a pilot project to tackle dengue using genetically modified mosquitoes by UK biotechnology company Oxitec, who hope that their method of controlling the mosquito population will cut the spread of dengue. Singapore’s MOH is investing S$1 billion in Jurong hospital project, reflecting the MOH’s commitment to raising healthcare standards for low income Singaporeans. At Jurong General Hospital, 75% of beds will be in the heavily subsidised Class B2 / C wards. The Philippines Department of Health on 12 October 2010 launched an expanded child health programme providing services and information on health, nutrition, and environment for newborns to 14 year-old children, allotting at least two billion pesos from its 2011 budget. A double blow of natural disasters in Indonesia in October and Novermber 2010 has left health services reeling, prompting calls for a disaster management ministry. Mount Merapi’s eruption and a tsunami created by a 7.7 magnitude earthquake in the remote Mentawi islands has left 500 dead.
Indonesia’s first wind power project broke ground early November. The 10-MW power plant in South Aceh is expected to help address the area’s ongoing electricity shortage. Malaysian automaker Proton is expected to release its first hybrid car this year at a price tag below RM100,000 (~US$32,400). Honda and Toyota are already selling hybrids in the country, though at prices higher than Proton's target. Malaysia has staked its claims on becoming an oil field services and equipment hub in Asia. Entry point projects have been devised to attract MNCs and investment. Accomplishing its goals as set out in the Economic Transformation Programme would create more than 20,000 jobs. The International Energy Agency (IEA) released the 2010 edition of its flagship publication, World Energy Outlook. The publication featured a prominent section on energy poverty and it was jointly produced by IEA, UNDP and UNIDO. The Asian Development Bank (ADB) agreed to lend 4.2 billion Thai baht to the Bangchak Petroleum Company for the construction of two solar plants in Ayutthaya. Funded through the ADB’s Asia Solar Energy Initiative, the projects will be completed next year and add 38-MW of installed capacity. Singapore’s Energy Market Authority has issued S$10 million to five local consortia under its Smart Energy Challenge. Award recipients will be focusing on three areas: power generation, energy for transport, and industrial energy efficiency. The Mekong River Commission issued a report stating that more than one million people dependent on fisheries for their livelihood would be negatively affected by further hydropower development in the Mekong River. US Secretary of State Hillary Clinton echoed civil society organisations in a recent press conference, urging precautionary review before initiating projects.
ASEAN leaders met in Hanoi, Vietnam, for the 17th ASEAN summit where regional integration and the ASEAN Master Plan for connectivity were discussed. APEC leaders met in Yokohama, Japan, on 13-14 November, where they agreed to intensify their efforts to create a Free Trade Area of the Asia-Pacific. During his visit to Indonesia, US president Barack Obama signed an agreement with Indonesia’s president, Susilo Bambang Yudhoyono, to deepen the bilateral economic and commercial relationship between the two countries. British Prime Minister, David Cameron, led a large delegation of ministers and businessmen to Beijing to improve trade relations between the countries. The Brits’ ambition was to include concerns about human rights issues as well as concerns for Nobel Peace Prize winner Liu Xiaobo in the trade talks. The attempts were however fruitless. Indonesia: A tsunami hit the islands of West Sumatra and was shortly followed by an eruption of the volcano Merapi. The difficulties to deliver aid to both places due to logistics issues put the spotlight on the need for infrastructure investments. Cambodia: the improved overall economic situation is reported to have significantly decreased the amount of non-performing loans by micro-finance institutes. Vietnam and Cambodia have signed a deal to lower tariffs to stimulate bilateral trade between the two countries, though they have yet to unveil which goods will see their tarrifs reduced.
Latest articles on www.asiantrendsmonitoring.com By 2036 “we’ll feel less healthy” and other predictions for the next 25 years...
New World Bank Paper on Measuring Energy Poverty
Ageing, healthcare consumption & spending: whose moral hazard?
Future health scenarios from the Guardian newspaper
An alternative method to an ambigious concept
The myth of unsustainable health spending
Ongoing trade dispute between #China & US about #cleantech, though now about DoD procurement - WTO rollback coming? http://nyti.ms/eOL4cs
OVERVIEW | 2
THE ROLE OF ICT AND HOW IT HELPS THE POOR In this issue we address information and communications technology (ICT) and its prospective role in enhancing development, reducing poverty, and empowering poor and marginal communities. For each of us who have worked on this issue, its seems an anathema that our use of computers, the availability of telephony, the internet, our twitter feeds, and our ready access to literally tens of millions of sites, research papers, books, journals, and other knowledge resources, are not widely enjoyed in developing countries. If we reflect more on this, it immediately becomes apparent just how vital are these technologies to our own productivity, teaching, knowledge, and research abilities, but also to our social networks and ability to remain connected with colleagues, friends, and family around the world. But imagine for a moment a world where these technologies were not so available, or if available were so costly that you could not afford to access them. What would this do to your knowledge horizon, ability to gather information, access financial services, or research topics related to your work and livelihood? Imagine further what impact this might have on your productivity, the economic opportunities available to you, your ability to learn, or hunt for employment. In such a world imagine how you would function when it came to daily transactions. How would you pay without a credit or debit card? Without a credit rating how would you acquire a loan to purchase a home, a motor bike, or finance a business? Without credit, how would you manage the irregularities of your employment and income, or the cyclical nature of your rice harvests? For a great majority of those living in Southeast Asia their realities are defined by only modest access to ICT, predominantly in the form of mobile phones and free-to-air
broadcast television. For still tens of millions of people, even this remains a far-off luxury where more basic services such as access to electricity has yet to arrive. In Indonesia, for example, 19 million households have no electricity service; some 40% of Indonesiaâ€™s entire population. Not surprisingly, more advanced technologies like computer ownership, broadband technologies, and high-speed fiber optic networks remain confined to a relative few â€” mostly located in urban areas and among the urban elite. In Southeast Asia, emerging domestic "digital divides" thus make for growing inequalities, unequal economic opportunities, with emerging longer-term developmental implications. There is, however, also reason for optimism. In this issue, we address some of the many success stories and pro-poor applications of ICT, and how these are empowering marginal and rural communities, improving economic well-being, trade and investment opportunities, the delivery of health services, and helping to raise public health outcomes. Equally, we address the environmental and energy downside of the increasing usage of ICT, looking at the problem of electronic waste, its disproportionate impact on the poor, and the implications of increasing ICT usage on energy demand in Southeast Asia. The story of ICT, its role in development, and impact on poor communities is a complicated one. We hope to provide a modest introduction to some of these complexities and the challenges that an on-going digital divide poses for the poor and governments in the region. Darryl S.L. Jarvis Associate Professor Lee Kuan Yew School of Public Policy National University of Singapore
Everybody wants to be connected to somebody.
BRIDGING THE ASIAN DIGITAL DIVIDE In developed countries the availability of informa-
creating a "digital divide" between those who have
tion and communications technology (ICT) is rela-
access to ICT and those who donâ€™t. Far from a mi-
tively ubiquitous as shown by near universal pen-
nor problem, the persistence of a digital divide has
etration rates, for telephony (wire and wireless), and
knock-on consequences that reinforce inequalities,
internet access through broadband and fibre optic
differential economic opportunities, and the rate
networks. Few of us in developed countries think
at which poverty and privations continue to impact
twice about using the internet or telephone in our
large swaths of poor communities in Asia. Increasing
work, to perform financial transactions, for research,
the availability of ICT has been identified as one of
or to purchase items online. In developing countries,
the primary instruments that can accelerate growth
however, this reality remains available to only a few,
and bolster the resilience of poor communities1.
TRADE & INVESTMENT FACILITATION | 4
While ICT attracts a relatively low proportion of trade and investment in developing countries compared to traditional sectors such as agriculture and manufacturing, as the World Bank notes its economic impact can be explosive.2 Indeed, there is increasing evidence to suggest that the careful application of ICT in selected sectors such as agriculture and commodities, which account for much of the livelihood among the rural poor in Asia, positively-correlates strongly with the development of new and often innovative economic eco-systems that bolster growth and increase market depth. These benefits typically accrue through three interrelated avenues. First, access to ICT helps to reduce information asymmetries, providing marginal communities with more and better quality information, increasing the knowledge economies of the poor and thus the range of economic opportunities available to them. Second, access to ICT provides network infrastructure that facilitates financial intermediation, business and economic transactions, and makes available savings and loans facilities at relatively marginal costs, increasing the participation rate of the poor in financial and monetised exchange
relations. Third, access to ICT helps improve the trading position of marginal and rural communities by making available real-time data about the prices of commodities, limiting the ability of wholesalers to be "price-setters" and thus increasing the financial returns to poor communities. Deploying ICT and increasing penetration and access rates is thus an obvious developmental instrument that can positively impact the poor. In Asia as elsewhere, however, the availability of ICT, the economic modality by which it is deployed and the level of competition allowed to operate within the sector, remain highly politicised domains with poor constituencies often disenfranchised from key decision making forums. ICT and the digital divide: emerging patterns In large measure, development is a function of the ability of nation-states to engineer innovation, apply technology to economic activities, and increase productivity. ICT thus plays a crucial role in the development equation. But while the application of ICT can create new economic opportunities and help governments leap-frog the development process, it can also reinforce inequities and set in place parallel
Mobile banking in Cambodia: financial empowerment for the poor It is estimated that only about 500,000 out of Cambodiaâ€™s 14 million population have a bank account; however, nearly three million people have a mobile phone. In early 2009, the mobile phone banking service Wing was launched by the Australia and New Zealand (ANZ) banking group. Today Wing has more than 150,000 users in Cambodia and the company estimates that they will have over 200,000 users in 2011. Wing is a SMS based-mobile phone payment service that aims to bring banking to people in rural areas by making it possible to do banking errands via local agents like a retail shop rather than having to visit a faraway banking branch. With mobile transfers, the risk associated with handling large sums of cash decreases significantly. The number of retailers associated with Wing has increased dramatically; in early 2009 there were 70 Wing agents, today there are about 500 across Cambodia. In the beginning, some 60 out of 70 agents were located in Phnom Pen. Today, they are spread throughout the country; however, a vast majority remain in urban areas. The Wing-project has made use of people-to-people knowledge transfer in order to spread the information about their
services. It recruits part-time staff to be physically present at market places and other gathering points in order to help customers to sign up for Wing. Most importantly, customers are taught how to use the service. Wing is covered by a banking license, a pre-requisite for its operations in Cambodia, and is thereby covered by the National Bank of Cambodiaâ€™s (NBC) regulatory framework. Over the past years NBC has significantly enhanced its regulatory framework to accommodate new types of banking, like the services provided by Wing. This is crucial to ensure safe transactions and to avoid scams, money laundering and financing of illegal activities. However, these new regulations have resulted in additional costs for the banks. Projects directed to the poor are highly sensitive to even the smallest increase in costs. Therefore, regulation must strike the right balance to ensure security but avoid being restrictive. The ambition for Wing and other mobile banking providers is to extend the services that can be carried out via mobile phones. ANZ is not the only company providing cheap mobile banking. What makes Wing special is the fact that it has managed to marry a sound business strategy with the social objective of providing a useful and essential banking service to the poor.
5 | TRADE & INVESTMENT FACILITATION
Figure 1: Mobile cellular subscriptions by level of development, 1998-2009 While the digital divide between developed and developing countries is abating due to economic advances in emerging economies (especially in Asia) and due to falling prices for ICT, globally millions of rural and urban poor have no or only rudimentary access to fixed or cellular phone networks.
Source: Adapted from ITU World Telecommunication / ICT Indicators Database
Figure 2: Internet users by level of development, 1998-2009
Internet access, especially broadband or fibre optic technology with high data transmission speeds, remains a luxury confined to high-income countries. Outside of developed Asia (Japan, South Korea, Hong Kong, Taiwan, and Singapore) internet availability is mostly confined to urban areas, tends to be "older" technology with slow transmission speeds, and relatively expensive as a proportion of weekly earnings compared to developed countries.
Source: Adapted from ITU World Telecommunication / ICT Indicators Database
TRADE & INVESTMENT FACILITATION | 6
Figure 3: Fixed telephone subscriptions per 100 inhabitants, by country group, 2000–2009
Fixed line phone penetration (or "copper wire" technology) is fast eroding as the main communications medium as technological innovations allow governments in developing countries to avoid the costly deployment of fixed line infrastructure and move into digital and cellular communications technologies.
Source: Adapted from Information Economy Report 2010, 2010.
economies that ultimately serve the national interest poorly. While the requirements of global competitiveness and modernisation compel governments to invest continually in the acquisition of new technologies and related infrastructure, in developing countries many of these investments are disproportionately captured by urban areas and the urban elite. ICT infrastructure, for example, is most often deployed as a means of servicing the technology requirements of foreign companies and the communications needs of high value-adding sectors like financial services, both as a means of attracting further foreign investment and growing strategic high-value adding tertiary sectors in the economy. But in developing countries where the vast bulk of the populace tends to be engaged in lower value-adding sectors such as agriculture, textiles, or the footwear industry, the benefits of ICT are seldom realised. This reinforces income and wealth inequalities, with the productivity gains associated with ICT and the economic opportunities they present, accruing disproportionately to the urban elite. How severe is Asia’s digital divide? In 2003 only 1% of Africans compared to 55% of North Americans had access to the web.3 In Asia, this figure is considerably higher. By one estimate 21.5% of Asia’s population has web access.4 However, this figure includes web access via thirdparty vendors (internet cafes) compared to home or business
access and does not acknowledge the technically inferior systems and slower transmission speeds, poor reliability, or inferior network capacities that plague ICT infrastructure in Asia. Thailand, for example, does not currently have a 3G network, while the Philippines only issued 3G licences in 2005, Indonesia, Southeast Asia’s largest economy, in 2006, and Vietnam as recently as March 2010. While the deployment of 3G networks in Asia represents a significant innovation aimed at closing the technical divide between emerging and developed economies, their deployment has not eradicated the paucity of internet and home / small business based internet access. Much of Indonesia, for example, has nominal to no 3G network coverage (confined mostly to the Jakarta region reflecting the economies of network density and deployment costs); a story that is repeated for the Philippines, Vietnam, Laos, and Cambodia. Equally, despite falling technology costs, particularly for cellular telephony, internet access remains an expensive communications technology for the vast bulk of Asia’s population. The cost of hardware requirements (computers or "smartphones") in addition to monthly subscription charges places it out of the reach of most Southeast Asian households, while the intermittent nature of network connectivity make web based communications relatively slow and unreliable. Where developed economies increasingly enjoy fibre optic networks and high-speed next generation
7 | TRADE & INVESTMENT FACILITATION
networks, for the vast majority of Southeast Asia’s 750 million people basic cellular connectivity remains their sole exposure to ICT — limiting the range of web based applications and thus the economic opportunities available to them. Expanding economic opportunities through ICT: getting the technology, finance and incentives right Governments in developing countries along with multilateral agencies all accept the need to increase ICT deployment as
a means to enhancing economic opportunity and economic well-being. The problem, of course, is finding the resources to do this and the value propositions to convince governments to allocate finite resources. But governments are not the only source of investment able to support ICT deployment. In fact, joint investments in ICT by government and small businesses in developing countries might hold the key to future technology innovations and growing economic opportunities. More importantly, the investment burdens required to deploy ICT can be greatly reduced by calibrating the appropriate
Experiencing Asia’s digital divide Bali is one of Indonesia’s 17,000 islands in a vast archipelago of some 240 million people. It is also one of Indonesia wealthiest regions (along with Java), enjoying international tourist arrivals and the injection of tens of millions of dollars annually through the legion of hotel developments that have sprung up on the island. But even in Bali, ICT remains a remote phenomenon for many Balinese. In Lovina, a small coastal community located in the north of Bali some three hours drive from the capital, Denpasar, Mr. Sudono Perkasa owns a small plot of land where he cultivates rice, along with his wife and two young sons. He is a member of the local subak, an association of rice farmers charged with the management of the land and water resources to ensure maximum land fertility and rice yields. Like his peers, Mr. Sudono reaps three rice harvests a year, enough to provide for the carbohydrate needs of his family and a small surplus that he sells via his cooperative for Rp7,000 a kilogram (about US$0.80). Combined with the sales of tourist merchandise which he and his wife trade (re-selling t-shirts and other apparel) along the black sand beach in Lovina, in-between rice planting and harvest seasons, Mr. Sudono is able to earn about US$250 a month.
go to a university. But he cannot afford a computer, let alone the monthly subscription charges for internet access. His oldest son, aged 13, is sometimes treated to an hour at the local internet cafe, which has three old computers and which the owner "rent out" at US$1 per hour. The only other alternative to access the internet is to use a portable device and log on to a local "hotspot". There are four local "hotspots" in Lovina, mostly for tourists to access the internet while on their holiday. But Mr. Sodono cannot afford a laptop, notebook, or iPad for his children, and the Rp25,000 (US$2.70) per hour access charge is almost three times what the local internet cafe charge and beyond his means. At their school, Mr. Sudono’s children do not have computers or internet access. Despite the learning advantages and opportunities he knows web access may provide for his children, Mr. Sudono cannot afford this luxury. Unlike children in developed countries, Mr. Sudono’s sons will grow up without the benefits of internet access, or the luxury of owning a computer. Mr. Sudono’s story is typical of the vast majority of households in Indonesia, where 19 million households (or roughly 40% of the population) remain without access to electricity let alone enjoy access to the internet.5
The family owns two cellphones connected through pre-paid phone cards which avoids monthly fixed subscription costs. Mr. Sudono explains that he cannot afford to sign on to a fixed cellular subscription system even though this would be cheaper per minute to operate because his income fluctuates month-to-month and is irregular depending on the season and quality of the rice harvest. Mr. Sudono has a modest two-room house adjacent to his rice paddy. Each room has a low watt flourescent bulb, and is sparsely furnished. He would like his sons to learn to operate a computer and be conversant with the internet and eventually
Rice farmers hard at work in Pupuan, Bali.
TRADE & INVESTMENT FACILITATION | 8
Private computer classes are available in Cambodia, but not many can afford them.
technologies to specific developmental needs. Governments, business and civil society groups are now learning that relatively inexpensive technologies applied in appropriate settings can have high economic returns and significantly impact the communities they serve. Looking ahead: ICT, trade, investment and the poor in Asia â€” a way forward? Few governments or multilateral agencies now doubt the benefits that accrue from the deployment of ICT in developing countries. The question for both governments and multilateral agencies, however, rests on what modality will best serve the interests of the poor, what technology is best suited to mass utilisation relative to cost and affordability, and how to ensure equity of access to ICT so that the benefits donâ€™t disproportionately accrue to urban areas, the urban elite , and thus contribute to maldevelopment and increasing inequalities. Ironically, most developing countries have opted for higherend ICT technologies, believing this will help to close the digital divide with developed countries. In the process, however, the relatively higher access and usage costs of this technology make it unaffordable to most rural populations, contributing to deepening domestic digital divides. Overcoming these domestic digital divides by calibrating the technology with affordability issues will prove the key for empowering rural communities and ensuring the externalities associated with ICT and widely and equitably distributed. Figure 4 suggests
a means of calibrating ICT with specific modalities and usage that involve poor communities and where ICT applications can have their greatest positive impact. The case studies presented here suggest that small- and medium-size private enterprise and civil society groups are ahead of the curve in terms of understanding the need to make ICT affordable to mass market participation both in terms of sustaining investment into the sector and in terms of ensuring widespread usage and technology uptake. This suggests a series of future intervention points that should drive the donor community as they approach questions of policy formulation concerning ICT. First, the governments of developing countries need to be educated about how ICT and technology investments can be disproportionately captured by specific economic groups and how this can create parallel economies and maldevelopment. While ICT is beneficial it can also have downsides and create unintended economic and social outcomes that hinder rather than drive inclusive economic growth. Second, investment into appropriate ICT technologies with the potential for mass uptake and affordable to the rural and urban poor needs to be encouraged. Too often higher-end ICT technology investments capture the interest of governments in developing countries, who are driven to close the technical digital divide with developed countries without understanding the domestic implications of such investments.
9 | TRADE & INVESTMENT FACILITATION
The Rice Knowledge Bank: source of life in Southeast Asia Rice is one of the most important crops in the ASEAN region; Thailand and Vietnam are among the world’s largest exporters. Many rice farmers are working in the same fields as their forefathers and are using the same archaic techniques. There is no doubt that ICT can make a difference. Through ICT rice farmers would be able to: • Access information and improve their knowledge on production techniques and best practices in rice farming; and • Get access to market price information and be in a more informed position when negotiating prices for their crops. Much knowledge is already available in the ASEAN region through the International Rice Research Institute (IRRI), one of the world’s leading research institutes on rice crop, located in the Philippines. But while research carried out at IRRI quickly finds its way to large agribusinesses, it rarely reaches the small rural farmers in the region. Thus, technical assistance in translating the knowledge and information from scientists to rural farmers is sorely needed. This is where the Rice Knowledge Bank (RKB), a joint project between IRRI and the International Maize and Wheat Improvement Centre comes in. The RKB’s main objective is to make information as accessible as possible for farmers by: • Keeping the information channel simple; a rural rice farmer who have never used the internet before should be able to navigate through the available information; and • Sticking with information that is of value and presenting the core message clearly to the farmer. The RKB is an internet-based project. Its website provides information about the production cycle, and shows pictures on crop diseases and how to treat them. The issues dealt with on the webpage largely builds on concerns highlighted by the farmers themselves. The site is designed to provide farmers with the most valuable information regarding farming without requiring advanced ICT-skills. While the information is only available in English on the main site, major rice producing countries have RKB sites in their local language. The website is supplemented by person-to-person knowledge transfer. The RKB has a project called Farmer Participatory
A farmer uses the computer at the International Rice Research Institute for new information on his crops.
Research, FPR, with the aim to include farmers in the research process and establish communication through "learningby-doing" between researchers and farmers. Through this low-tech knowledge transfer farmers are also taught about ICT and the practical- and research-based materials to help improve crop yields and rice production. It is well known that in developing countries, the use of mobile phones is much more widespread than internet access. So the RKB is further supplemented with a text-messaging service where farmers can call or send text messages to experts at the IRRI. However, this service can be much improved. The project is based on a grant and not self-sufficient. The risk is that it cannot be sustained in its current form despite its cost effectiveness and high returns for the rice farmers.
TRADE & INVESTMENT FACILITATION | 10
Figure 4: Conceptual map of ICTs, enterprise and the poor
Source: Adapted from Information Economy Report 2010 and UNCTAD 2010
Third, small- and medium-size private sector interests have shown the way forward in terms of calibrating the appropriate ICT technologies with mass-market utilisation. Helping policymakers develop the appropriate investment and regulatory modalities to encourage more of this investment is essential if Asia’s poor are to enjoy the economic opportunities provided by ICT.
Fourth, regulations on foreign direct investment should be liberalised to create incentives for providers to supply rural areas with affordable ICT solutions. Current restrictive and protectionist measures do not serve the interests of poor communities in Asia.
4. Internet World Stats. 2010. Internet Usage in Asia. Retrieved 20 December 2010 fromhttp://www.internetworldstats.com/stats3.htm.
Fifth, mobile phones are the most commonly used ICT tool in developing countries — especially in rural areas. Investments in mobile telephony and universal coverage is critical if rural communities are to access ICT and enjoy the economic opportunities it provides.
Asian Development Bank. 2010. ICT-related Projects by Year of Approval. Retrieved from http://www.adb.org/documents/ICT/projects-year.pdf#page=33
Sixth, education on how to use ICT is crucial. ICT uptake is not automatic but has a learning element associated with it. Intervention points designed around basic capacity building at the local level remain important for effective knowledge transfer and ICT utilisation.
1. 0The World Bank. 2010. Employment in agriculture (% of total employment). Retrieved from <http://data.worldbank.org/indicator/SL.AGR.EMPL.ZS> 2. 0The World Bank. 2010. Employment in agriculture (% of total employment). Retrieved from <http://data.worldbank.org/indicator/SL.AGR.EMPL.ZS> 3. 0UNCTAD. 2005. ICT and e-business: what developing countries stand to gain. Issues in Brief, 11, 1-2.
5. 0Jakarta Globe (2010a) SBY inaugurates‘Blackout-Free’Era. July 28. http://www. thejakartaglobe.com/business/sby-inaugurates-blackout-free-era/388131
Nwagwu, Williams Ezinwa. 2006. Integrating ICTs into the Globalization of the Poor Developing Countries. Information Development, 22, 167-179. Sidorenko, Alexandra, and Findlay, Christopher. 2001. The Digital Divide in East Asia. Asian-Pacific Economic Literature, 15, 18-30. The World Bank. 2010. Employment in agriculture (% of total employment). Retrieved from <http://data.worldbank.org/indicator/SL.AGR.EMPL.ZS> United Nations. 2010. Information Economy Report 2010: ICTs, Enterprises, and Poverty Alleviation. Retrieved from <www.unctad.org/en/docs/ ier2010_embar``1``>
EMPOWERINGTHE POOR AGAINST CLIMATE CHANGE ICTs have been central in making the world flat, as
regularity of Berlinâ€™s teenagers, but rural farmers
Thomas Friedman declared in his 2005 bestseller,
are increasingly leveraging common devices like
but what is not flat is how they are being used. Us-
cellphones and radios for their direct benefit, be it
age differences among age groups, rural and urban
through commodity price updates or world news
groups, across continents and across income brack-
coverage. Regardless, inter-group differences are
ets remain stark. This is obvious enough. You may
rapidly dissolving as expanding networks and de-
not find Cambodian rice farmers from Preah Vihear
creasing costs connect even the most remote rurali-
province updating their Facebook status with the
ties to the global commons.
ENERGY SECURITY | 12
As the prevalence and variety of ICT devices increases, so too will their energy requirements. According to a 2007 study conducted by Gartner, a leading IT research and advisory firm, the production and use of ICTs is responsible for an estimated 2% of global greenhouse gas (GHG) emissions, equivalent to that of global aviation.1 Major IT companies, like Google, have been at the forefront of reversing this trend by reducing their environmental impact through "green ICT" solutions. This has not exempted them from public scrutiny. Google and Facebook, because of their visibility and massive computing requirements, are often in the crosshairs of campaigns to promote green IT. For them it is often a battle of incremental gains. Breakthroughs in cooling technology or processor density are briskly erased by expanding user numbers and storage demands. Powering servers with renewable energy may not be the only solution. A 2008 McKinsey & Company report stated that “we fully expected to find that building ‘green,’ energy efficiency data centres would offer the best value for our clients. What we learned instead was that the ‘greenest’ and most costeffective opportunities were in improving the efficiency of data centres that the clients already owned.”2 In some cases, they observed servers never exceeding utilisation rates of 6%, but still drawing power which could be avoided through improved data centre design. Then there is the other camp. ICT proponents like Dennis Pamlin, currently with the Chinese Academy of Social Sciences, and Bill St. Arnaud of St. Arnaud-Walker and Associates, argue that
demonising ICTs’ energy consumption is myopic and ignores ICTs’ tremendous scope for displacing some of the other 98% of emissions.3 As a mitigation tool, the energy gains made by ICTs through journey substitution (e.g. tele-commuting, video-conferencing), dematerialisation (e.g. reducing demand for packaging and paper products), and improved facilities management (e.g. optimising temperature and lighting controls) is manifold greater than the energy ICTs themselves consume.4 IDC, another IT industry research group, last year released a white paper that mapped out how vigorous ICT deployment in four key sectors (power, industry, buildings, and transport) could reduce G20 countries’ GHG emissions by 25% over 2006 levels.5 These are undeniably substantive issues for high-income groups where long-distance travel and broadband internet access are taken for granted, but of little relevance to the poor who don’t own cars, cannot afford air travel, and whose consumption of other goods and services is limited at best. Until they gain middle-class purchasing power, for them the thread connecting energy or climate issues to ICTs will remain an entirely different colour. Their ongoing concerns will be in ensuring reliable electricity to operate ICT devices, employing ICTs for natural resource management, and improving disaster forecasting and alert systems. ICTs and climate change adaptation For years, climate change researchers had viewed ICTs through the lens of facilitating GHG mitigation efforts.6 Only recently, according to researchers at the University of Manchester’s Centre for Development Informatics, has some of
Figure 1: Rural examples of ICTs in climate change applications
13 | ENERGY SECURITY
that attention shifted to mobilising them for adaptation activities in developing countries.7 In this context, they bring a twofold set of benefits: both in unlocking and accelerating access to greater volumes of information that have direct impact on livelihoods, and in expanding the number of formats by which this information is relayed and received. These contributions are especially salient in crises where information must urgently be dispatched to affected areas, all whom have varying access to communication devices. While the transformation and increasing dependence on ICTs can be seen as a deepening and widening of how information is transferred, the real innovation in this recent wave of ICT "democratisation" is the bi-directionality of these information flows. Whereas traditionally dominant information services like TV and radio adopt a top-down model, the penetration of personal devices and network connectivity has created ripe opportunities for compiling data and experiences from disparate grassroots sources. This change will be revelatory in promoting climate change adaptation. Community organising, climate change, and ICTs In late November 2010, negotiating teams from around the world again met in a bid to construct a post-Kyoto climate architecture. While pessimism that a robust, binding agreement would materialise was the prevailing sentiment, civil society organisations in particular were adamant for progress to be made. To support their efforts, they have increasingly employed ICTs to foster a two-way dialogue. For example, organisations like the United Nations University’s Institute of Advanced Studies Traditional Knowledge
Scenario 2018: Vietnam, Typhoon Iris Around 2:45am on September 23rd, Typhoon Iris made landfall on southern Vietnam’s Binh Thuan province with wind speeds exceeding 73 knots and mean sea level pressure dropping below 920 millibars. The typhoon’s eye then veered south, causing moderate damage to Ba Ria-Vung Tau province before returning eastward and weakening in the South China Sea. The final death toll stood at 15 with property losses estimated over US$165 million, though were considered mild against the aftermath of similarly powerful Typhoons Susang (2011-163 deaths), Patsy (2013-93 deaths), and Olga (2015237 deaths). Vietnam’s Central Committee for Flood and Storm Control (CCFSC) credits the implementation of their National Strategy for Natural Disaster Prevention, Response and Mitigation for
Initiative (UNU-IAS TKI) and the Andrew Lees Trust are assisting communities in producing videos about the environmental challenges they face. These videos have then been screened at film festivals and United Nations Framework Convention on Climate Change summits, bringing the "local" to the "global." In preparation of the 2009 Copenhagen meeting, the UNU-IAS TKI worked with Alaskan Inuit organisations to produce footage that would be watched by policymakers, informing them of the adaptation needs of indigenous communities.8 The same tools work in reverse when organisations like Panos London, in collaboration with the International Institute for Environment and Development (IIED) through their Climate Change Media Partnership, support journalists from the Global South to attend and report from major climate change summits. These reporters use a variety of media including community radio, newspapers, tape recordings, and storytelling to reach their home audiences and communicate climate policy and science in an understandable manner. Since the content is locally-produced, it is more likely to mobilise action than generic broadcasts issued by developed country media outlets.9 Only when this information becomes available, which it has not, will communities learn about the potential risks they face and act to minimise them. Early warning systems and natural disasters Climate change projections foretell an increase in the frequency and intensity of natural disasters. However, the losses associated with these disasters, whether floods, hurricanes, or earthquakes, can be dramatically reduced when networks
the minimal losses. Minister of Agriculture and Rural Development, Dr. Nguyen Son Lam, stated that the National Strategy forced relevant agencies to identify effective solutions, both policy and technology based. Among them were the integration of ground-based GPS receivers to gather real-time data from meteorological satellites and an advanced alert system that would transmit to radio, mobile, and TV. Aside from systems improvement measures, such as compulsory disaster response training for all first responders, MARD has embarked on an ambitious mangroves restoration campaign. Since Typhoon Wukong struck in 2000, the value of mangrove forests as a buffer against disasters became apparent. Directives issued shortly thereafter created competition with shrimp farmers who discreetly cut back mangrove growth. After adopting a GIS-based monitoring system in 2013, efforts could be concentrated on the most vulnerable segments of the coastline.
ENERGY SECURITY | 14
Figure 2: Drivers and by-products of electronic waste
of satellites, seismometers, sensors, and gauges rapidly relay actionable information to the appropriate authorities. Despite technological advancements, developing fail-safe warning mechanisms will continue to be a challenge. The Colombo-based LIRNEasia, an ICT policy and regulation think tank, has investigated various ICT-based warning systems whose effective, pre-disaster use could minimise death tolls and damages. In upgrading their warning system, the Telecommunications Authority of the Maldives had considered both cell broadcast (CB) and short message service (SMS) options and commissioned LIRNEasia to evaluate the two. Researchers found several advantages tied to a CB platform. Messages configurable by geographic area, instantaneous dispatch to millions of potential users, and restricted dispatch access to safeguard against fraudulent alerts were just some of them. However, the major trade-off with CB is that, unlike with SMS, messages do not queue up when the mobile device is turned off. Regardless, the commissioning
of this research alongside similar discussions in the Philippines, Indonesia, Vietnam, and Sri Lanka, especially after the 2004 Boxing Day Tsunami, indicates rising awareness of how ICT deployment can improve forecasting capability and ultimately save lives. The flooding in Pakistan this past summer offers a case in point of how ICTs can be used on the ground to expedite disaster relief and direct resources to where they are needed most. Twitter users like @sawant and @faisalchohan in early August were appealing to other users of the micro-blogging service to mobilise aid in what would eventually be a disaster causing US$9.5 billion in damages.10 Another outreach effort was made through the quick construction of the PakReport map, a crowd-sourced, dynamic map with category layers that was modeled on the open-source Ushahidi platform,11 first created in 2008 to track violent incidents in post-election Kenya. Cellphone users in Pakistan could send an SMS to 3441 to identify their location and register the areaâ€™s
15 | ENERGY SECURITY
Rural Cambodia leapfrogged over fixed-line telephony.
immediate problems, such as drinking water shortages or rioting, which was immediately added to the PakReport map. Individuals with internet access could submit more extensive reports.12 Given the limited number of aid workers operating in post-disaster areas and the tremendous value this grassroots information represents, examples of ICT mobilisation for humanitarian purposes, like those listed on the ICT4Peace inventorisation wiki, will only grow in time. Geographic information Aside from humanitarian purposes, technologies like remote sensing and geographic information systems (GIS) have been used for monitoring natural resources, such as mangrove forests in Kenya,13 and then determining how best to sustainably manage those resources. Three-dimensional, participatory mapping work is currently taking place in Southeast
Asia, through Participatory Avenuesâ€™ Integrated Approaches to Participatory Development (IAPD) project. Relying on local knowledge, Participatory Avenues in conjunction with governmental and CSO partners have thus far generated maps in the Philippines, Cambodia, Vietnam, and Malaysia that will foster biodiversity and habitat protection, coastal area management, and mitigate resource-driven conflicts.14 New plugins for the Google Earth application perform similar functions, offering users visual insight into countriesâ€™ changing forest cover over time, thereby improving awareness of deforestation trends. These monitoring tools will be essential to national and international environmental organisations in the implementation of climate change instruments like the UNâ€™s Reducing Emissions from Deforestation and Forest Degradation in Developing Countries (REDD). On the energy front, GIS-based tools have entered into rural electrification planning, in ASEAN most notably through the Rural Electrification and Decentralised Energy Options (REDEO) project which received support from the European Commission-ASEAN Energy Facility. Through this programme, partner countries Laos, Cambodia, and Vietnam gained access to forecasting tools to identify areas where electricity grid extension would likely occur. Off-grid electrification efforts could then be better targeted to outstanding unelectrified areas. Energy supply reliability: powering ICTs
ICTs expedited relief support for Pakistan's flood victims.
Reliable electricity access is critical for these communications tools to be useful in times of crisis, which is lacking in much of the region. Less than a quarter of the population in countries
ENERGY SECURITY | 16
like Myanmar and Cambodia have access to electricity and countries with higher access rates cannot guarantee stability. Even after the dry season which crippled much of its hydropower capacity, parts of the Philippines are still suffering daily power outages of 8-12 hours,15 indicating that critical applications may require power fed through alternative sources instead of the grid. While diesel-powered generators may be one remedy for intermittent electricity access, they are expensive and unreliable in areas with unpredictable fuel deliveries. One example of this intermittency problem comes from Kafanchan, Nigeria where the Fantsuam Foundation, a non-profit organisation promoting community development and ICT training, is based. They recognised that their existing electricity supply was too unreliable to power the community wireless network they planned to install and the solution they previously adopted was too costly; 80% of their electricity expenditure was spent on diesel generation at an operating cost of US$20 an hour.16 With financial support from the Canada-based IDRC, they were able to purchase 24 80Wp solar panels that would supplement the grid electricity and diesel generator, with excess charge stored in deep-cycle batteries. This hybrid system now powers Nigeria’s only rural wireless internet service provider (ISP), Zittnet, which is anticipated to later extend across a 70km radius covering southern Kaduna state. In the meantime, the ISP continues to provide data and telephony (VoIP) services to several small businesses, a hospital, an internet cafe, a hotel, and a health clinic. Around the corner Just as nobody 20 years ago could have foreseen the ubiquity of cellphone ownership by rural farmers who earn less than US$2 a day, we have only a limited view of what remains around the corner. For now, the relationship between energy / climate change and ICTs will stay bidirectional; ICTs can provide direct benefits to the poor by providing information about energy use (e.g. smart meters) and climate change (e.g. satellite imagery and natural disaster forecasting), but only when there is sufficient power to operate the devices. When electricity becomes more widespread, poor households will not have to rely on private mobile phone charging services, for example, which will also result in cost savings. As internet bandwidth costs drop, access to data-intensive applications will also improve, opening up entirely new opportunities. The poor will then be more empowered with information about how climate change may affect their communities and act to mitigate those risks.
References 1. Gartner. 2007. “Gartner Estimates ICT Industry Accounts for 2 Percent of Global CO2 Emissions.” Available at: http://www.gartner.com/it/page.jsp?id=503867 2. Kaplan, James M.; Forrest, William and Noah Kindler. 2008. “Revolutionizing Data Center Energy Efficiency.” McKinsey & Company. Available at: http://www. mckinsey.com/clientservice/bto/pointofview/pdf/Revolutionizing_Data_Center_Efficiency.pdf 3. WWF. 2008. “From Fossil to Future with Innovative ICT Solutions: Increased CO2 Emissions from ICT Needed to Save the Climate.” Technology for Better Business Outcomes, Barcelona, 17-19 March. Available at: http://www.pamlin.net/written/ documents/Fossil2Future-WWF-ICT.pdf 4. Houghton, John. 2009. “ICT and the Environment in Developing Countries: An Overview of Opportunities and Developments.” Communications & Strategies, 1 (76) 39-60. 5. Turner, Vernon; Bigliani, Roberta and Chris Ingle. 2009. “Reducing Greenhouse Gass Through Intense Use of Information and Communication Technology: Part 1.” IDC White Paper. Available at: http://download.intel.com/pressroom/archive/ reference/IDCWP31R.pdf 6. For more information about ICTs and climate change in general, see the comprehensive ITU. 2008. “ICTs for e-Environment: Guidelines for Developing Countries, with a Focus on Climate Change.” ICT Application and Cybersecurity Division. ITU: Geneva. Available at: http://www.itu.int/ITU-D/cyb/app/docs/itu-icts-for-eenvironment.pdf 7. Ospina, Angelica Valeria and Richard Heeks. 2010. “Unveiling the Links Between ICTs & Climate Change in Developing Countries: A Scoping Study.” Centre for Development Informatics, University of Manchester. Available at: http://www.niccd. org/ScopingStudy.pdf 8. BCO Alliance.2009. “Planting the Knowledge Seed: Adapting to Climate Change Using ICTs.” Eds. Patrick P. Kalas and Alan Finlay. Available at: http://www.bcoalliance.org/Climate-Change 9. Osterwalder, Alexander. 2007. “ICT in Developing Countries: A Cross-Sectoral Snapshot.” Available at: http://www.hec.unil.ch/aosterwa/Documents/InternetInEmergingMarkets/Publications/ISGLOB03.pdf 10. Reuters. 2010. “Pakistan Flood Damages $9.5 bln – Officials.” 13 Oct. Available: http://in.reuters.com/article/idINIndia-52159420101013 11. For more information, visit http://ushahidi.com/. 12. For more information, visit http://pakreport.org/ushahidi/main. 13. Kairo, J.G.; Kivyatu, B. and N. Koedam. 2002. “Application of Remote Sensing and GIS in the Management of Mangrove Forests Within and Adjacent to Kiunga Marine Protected Area, Lamu, Kenya.” Environment, Development and Sustainability. 4 (2) 153-166. 14. For more information, visit http://www.iapad.org/index.htm. 15. Regalado, Edith. 2010. “Up to 12-Hour Power Outages Still Hound Parts of Mindanao.” The Philippine Star, 30 Sept. Available at: http://www.philstar.com/Article. aspx?articleid=616473 16. Fantsuam Foundation. 2006. “A Solar Powered Electricity Backup System for Fantsuam Foundation’s Community Wireless Network – Project Proposal.”
The Energy Security section greatly benefited from the insights of Bidi Bala (Fantsuam Foundation), John Dada (Fantsuam Foundation), Alan Finlay (Open Research), Sriganesh Lokanathan (LIRNEasia), Karel Novotny (Association for Progressive Communications), Visoot Phongsathorn, Saowaruj Rattanakhamfu (Thailand Development Research Institute), Chanuka Wattegama (LIRNEasia), and Shazna Zuhyle (LIRNEasia).
Much to do before the effects of ICT trickle down to the poor.
ICT LEADS TO BETTER PUBLIC HEALTH? In resource-poor settings, lack of existing infrastruc-
phone really compensate for face-time with a health
ture and backup systems mean that well designed
worker? The concerns of the resource poor must be
e-health solutions may have a bigger impact on the
explicitly considered when assessing the impact of
quality of care in developed areas.1 ICTs facilitate in-
ICTs on health outcomes. Is there any evidence that
formation exchange, compressing time and space to
systematically shows improvements in individual or
deliver information faster, often at lower financial and
population health that has been facilitated by ICTs?
opportunity costs of time. The ability of the poor to ac-
This section seeks to illuminate these issues. To start,
cess information may be enhanced, but can a mobile
what exactly are the main ICT applications in health?
HEALTH SYSTEMS | 18
Optimism abounds when considering the prospects for health systems strengthening via ICTs; their potential returns to scale hold massive appeal for governments, donors and investors. ICT applications in health have exploded in recent years, with functions like health communication (e.g. preventative education), patient compliance and monitoring, demographic and health data collection and early warning systems for disease outbreaks. Innovations include use of mobile signals as an alternative internet broadband in remote areas in the Philippines, and open source software and mobiles to transmit X-rays from rural areas to doctors in cities. There’s a buzz about handheld audiovisual devices that assist specialists to carry out “remote” diagnosis and treatment via frontline community health workers. On the high technology side, bio-monitoring devices that report up to the minute information on health metrics e.g. blood sugar, are being piloted and tested globally, but whether these technology reach the poor will depend on investment, corporate social responsibility and the political will to do so. E-health is defined as the use of emerging interactive technologies (e.g. internet, personal digital assistants, CD-ROMs, interactive television and voice response systems, computer kiosks, mobile computing) to enable health improvement and health systems functioning.2 E-health also encompasses information systems that are at the edge of medicine or healthcare and information technology (See Figure 2). ICT applications are suitable for some health functions, but not all ICTs can be used for better and more health data collection; this can fundamentally save lives. In collaboration with the WHO’s Southeast Asia Regional Office, Cambodia’s Ministry of Health in 2010 set up a Maternal Death Surveillance Room in Phnom Penh, which tracks data from around the country to give health officials real time information on the number of women dying in pregnancy and childbirth, as well as their location.3 Deaths are reported by a local health worker, family member or village leader using a cellphone to call a toll free number linking them to their district health authority or MOH (mobile network coverage was 87% in 2008). Reports are then passed to the maternal death surveillance room for verification. This is a major improvement on the prior system, where maternal deaths were notified only if a woman died in hospital or health centre. In Cambodia, many deaths take place at home or on the way to a hospital or clinic, which doesn’t show up in national statistics. The aim of the surveillance room is to ultimately bring down the number of maternal deaths, using better data to pinpoint weaknesses in the care of pregnant women, and rectify them. Cambodia is lagging behind on MDG goal-5 “improve maternal health” by 2015, with 461 per 100,000 births recorded in the 2008 census. Whilst it’s too early
to assess the surveillance’s room’s efficacy and impact of better data on reducing maternal deaths, using ICTs to improve data collection flows is perhaps one of its simplest and most powerful applications in health. It’s been questioned whether ICTs are a suitable medium for all healthcare functions — for example, is it really appropriate to diagnose and treat patients via email? A systematic review of research on email communication between patient and doctor concluded that different types of media are appropriate for different functions. Email is fine for giving health information but diagnosis and treatment require more
Improving healthcare delivery via telemedicine in Northeastern Philippines Sleek smartphones are being used to transmit X rays from remote areas to radiologists in cities, dramatically reducing the time it takes to diagnose TB in patients in Batanes. The brainchild of MIT graduates, non-profit organisation Sana aims to bring cellular technology to remote areas to improve access to medical specialists for fast, high quality and cost effective diagnosis and intervention. Their open source software encourages adoption and supports audio, images, text and in future video sent via cellphones (See Figure 1).4 Now a local developer community has been set up via the Sana mHealth lab at the Asia Pacific College in Manila, so that software and technology can be tailored to local requirements. Potential to roll out telemedicine for those living in islands and other remote areas in the Philippines is extremely high given that 99% of the population is covered by a mobile network.5
Figure 1: Sana process and interface
19 | HEALTH SYSTEMS
Figure 2: ICT applications in medicine and healthcare
advanced telemedical technology to personalise the encounter (e.g. videoconferencing between patient and doctor)7. But, itâ€™s been suggested that remote diagnosis is inappropriate or unethical â€” face to face patient contact with a health worker and the personal touch that comes with physical meetings may be better suited for diagnosis. For the poor, issues with literacy and connectivity (see emerging trends section) mean that physical presence of a health worker to clarify complex health information is appropriate if advanced video-conferencing technology is not available. But, we canâ€™t
be sure without proper evaluation which ICTs work best for the poor in all functions. Research into the types of health information channels that the poor prefer must be carried out so that providers or governments can reach them in a way that will improve health status. In the case of the poor, we have to ask what the utility is of say, having a mobile that transmits appointment reminders, but a lack of nutritious food or basic sanitation. Vietnam for example has 100 plus mobile phone subscriptions per 100 inhabitants, but just 41% of the population enjoys basic sanitation (falling
HEALTH SYSTEMS | 20
Figure 3: Households in Southeast Asia with TV set by country
Source: Wagstaff J (2010) Southeast Asian media: patterns of production and consumption: a survey of national media in 10 countries of Southeast Asia, Open Society Institute Media Programme. Available at: http://www.soros.org/initiatives/ media/articles_publications/publications/production-consumption-20100126 (accessed on 1 November 2010)
to 26% in rural areas).8 In resource allocation, governments would do well to remember that basic, physical infrastructure development should precede any premature efforts to roll out sexy, high tech health applications. Mass media and health info dissemination: TV, radio, social networks and physical spaces Let’s not discount what’s already there; TV and radio present a significant opportunity for information dissemination to the poor; they have been shown to migrate to television — although this is dependent on electricity access rather than wealth.9 In the first report of its kind, Open Society’s media programme surveyed media patterns of production and consumption across ASEAN countries and they found that whilst cellphones are becoming the new computer or newspaper, televisions remain the main source of information for Southeast Asians. A key challenge here is providing accurate and useful content; TV channels have remained in the hands of political elite, and on a national scale, public service broadcasting remains small scale and has done little to challenge this. When it comes to health promotion, arguably good quality public channels (not influenced by corporate interests) are best positioned to deliver accurate health information to consumers. Mass media campaigns designed to raise awareness of HIV and AIDS have shown immediate and significant effects in the promotion of voluntary counselling and testing for HIV, according to a Cochrane systematic review.10 Whilst further research is needed to identify possible effects on HIV positive status following mass media campaigns, the review points out the crucial role of mass media in prompting health seeking behavior in consumers. In Asia, the poor are more likely to
forgo or delay consumption of health services than wealthier groups (due to lack of money or time to visit health facilities)11,12. More mass media campaigns in health could prompt health seeking behavior by the poor if accompanied with financing schemes, as well as generate an overarching “healthy cultures” environment. Brunei has enlisted the help of DJs and TV presenters to scale up health promotion efforts in the kingdom. The Ministry of Health hosted special health seminars in March 2010 to educate presenters on health related issues and highlight their role in driving home essential messages about healthy lifestyles to their audiences. Senior medical staff are optimistic about using established mediums to reach the Brunei population — "If you listen to the radio, it's more interactive with the public because you have open phone lines, you can text or email the DJs. I can easily see DJs telling people about health guidelines on how many portions of vegetables they need to eat on their way to a big family dinner," said Senior Medical Officer Dr Hjh Norhayati Hj Md Kassim.13 Brunei has the highest prevalence of obesity in Southeast Asia with over 60% of adults being overweight; chronic disease also accounts for almost 90% of all adult deaths, again the highest in Southeast Asia. In the next ten years, leveraging established mediums like TV and radio for health messages and campaigns will prompt better health seeking behaviour and promote consciousness of healthy lifestyles amongst rich and poor alike — central in the global fight against chronic disease. Governments must create overarching healthy cultures via mass marketing campaigns and better design of the built environment, before the silent epidemic of chronic disease ruptures. It’s a virtuous cycle: humans learn by social cognition and observation; recent social network analysis shows
21 | HEALTH SYSTEMS
that individuals are more likely to become depressed, obese or smoke if a friend or a friend’s friend is, with increasing likelihood if more individuals in the network display these characteristics.14,15 So getting that macro environment right is crucial; using ICTs for health information dissemination will accelerate as technology scales up and content or production costs fall. Singapore’s government has taken a holistic approach to create healthy cultures using ICTs and public spaces. The health promotion board’s “Lose to win” TV reality show challenges participants to lose the most weight in the healthiest way. The show has attracted unprecedented interest in its 2nd season, registering 1,500 participants.16 HPB also provides interactive tools on their website e.g. diabetes risk assessment. But it’s not enough; physical, public space must be utilised too. Warnings about dengue fever on buses, and outdoor gym equipment in public housing estates, helps to mind the health equity gap between rich and poor in the city state, which has one of the highest levels of income inequality in the world.
lower income populations, indicates that voice or visual communications (e.g. community TV or radio) will have more impact amongst the poor. Health information must be communicated in local languages, with health jargon simplified, channeled via mediums preferred and used by the poor. For someone recently diagnosed with an illness, prognosis and treatment information are likely to be foreign and even daunting, requiring learning in the context of stress and even fear. Making decisions in this context is a complex process that may involve a wide variety of interpersonal interactions, as well as information requirements. Getting frontline health workers into remote areas is just as important as providing them with the latest technology to facilitate better decisions by patients.
Skills for interpreting various forms of health information and integrating them into one’s health decisions vary widely across populations.17 The complexity of health information, coupled with low literacy and numeracy levels amongst
With the spread of internet access across Southeast Asia, and uptake by the poor, there is a risk of inaccurate self diagnosis from the wealth of health information available online. Evidence from a recent literature review suggests that consumers in developed countries gravitate towards the net for self care and technical advice, but that information found seems to generate anxiety and doubt about meaningful clarifications. Furthermore, consumers seem to have difficulty in identifying and naming their own symptoms, in addition to having to choose between shallow and alarmist advice.19 This could
Infectious disease outbreak early warning system in the Mekong Basin Region
them to each other and managers to accelerate outbreak response and spread information to villages.
Southeast Asia is a hub for newly emerging infectious diseases like SARS, H1N1 and H1N5, alongside the usual malaria, dengue and TB. InSTEDD (Innovative Support to Emergencies, Diseases and Disasters)18 works with the Mekong Basin Disease Surveillance (MBDS) network to strengthen regional surveillance and response systems in Cambodia, Thailand, Vietnam, Southern China and Laos. They accomplish this by developing and rolling out locally customised open source software tools, making it easier for governments and other agencies concerned with infectious diseases to work together, share information, hypothesise threat evaluation and make better decisions during outbreaks. One such tool is GeoChat, designed to facilitate group communication in areas where internet networks are poor or non existant. It uses mobile networks to allow users to link the field, HQ and local community in a real-time, interactive conversation visualised on a map (See Figure 4).
InSTEDD also seeds “innovation labs” where local personnel are trained to co-develop software tools and methods, so solutions match the realities on the ground, linked to a global network of open source public health software developers.
Health information processing and the poor
Geochat is being used by the Ministry of Health in Cambodia to report disease outbreaks, send staff alerts and organise responses to outbreaks. It is also being used by 600 community health workers in Mukdahan province, Thailand to connect
Figure 4. GeoChat interface
HEALTH SYSTEMS | 22
be the case for Southeast Asians too; establishing reputable online portals for health information (e.g. Singapore’s Health Promotion Board, Vietnam’s Ministry of Health online drug portal) will be essential in the fight against inaccurate medical / health information. Around the corner: better research, scaling up, local content, TV and radio Testing what works and what doesn’t will be especially important before massive investment in large scale / national ICT projects, and rigorous evaluation will become more commonplace as governments face competing fiscal demands and accountability. Randomised evaluations in ICT applications in health are emerging. MIT’s Poverty Action Lab (JPAL) is staging a randomised evaluation to test whether innovative user technology in primary health centres in India can address systemic problems like absenteeism, leakages and poor epidemiological data.20 In the next five years, television and radio remain the most accessible forms of ICTs. They will play a greater role in health information campaigns — but the threat is that "Big Food" MNCs or tobacco companies use these mediums to advertise cigarettes or junk foods; governments must regulate them to protect consumers. In general, new innovations in technology will continue to move in advance of the law and governments must stay tuned to keep pace of new developments and beware of potential threats. As the energy section highlights, the poor require reliable sources of low cost energy to power these mediums — which may or may not materialise given underinvestment in e.g. electricity infrastructure. Investment in ICTs for health will continue to be driven by foundations or donors; examples of successful pilot projects will be scaled up by governments who must take the lead in expanding access to ICTs and reliable energy to power them. Pro-poor ICT interventions will fail if they do not integrate stakeholders — health workers, consumers — into design and implementation, e.g market research into preferred mediums. Health workers in developing countries may lack the ICT skills to benefit from online medical resources, distance learning or computer based training. There is a major risk of implementation failure if health workers are not integrated into application design and receive adequate training in how to use ICTs. As demand for healthcare increases, and doctor’s time is increasingly strained, leveraging ICTS in chronic disease treatment and management will be key as chronic diseases explode in the next 20 years. A prevention focus today will pay dividends for younger populations, but for today’s middle aged to older populations at risk from long term chronic disease, it may be too late.
References 1. Blaya JA, Fraser HSF and Holt B, “E-health technologies show promise in developing countries”, Health Affairs, Feb 2010, 29:2 p. 244 – 251 2. Ahern DK, Kreslake JM and Phalen JM, “What Is eHealth (6): Perspective on the Evolution of eHealth Research”, Journal of Medical Internet Research, vol. 8, No. 1 (2006), http://www.jmir.org/2006/1/e4/ (accessed on 29 October 2010) 3. The Phnom Penh Post. Maternal death surveillance praised. 13 October 2010. http://www.phnompenhpost.com/index.php/2010101343944/National-news/ maternal-death-surveillance-praised.html (accessed on 1 November 2010) 4. http://www.sanamobile.org/about.html (accessed on 1 November 2010) 5. International Telecommunication Union, World Telecommunication Development Report and database, and World Bank estimates 6. Futuregov (2009). Planning Ahead – Is Asia’s Healthcare Sector Ready for the Future? http://www.digitalopportunity.org/feature/promoting-it-in-healthcare (accessed on 1 November 2010) 7. Eisenbach 2000 in InfoDev (2007) “Improving health, connecting people: the role of ICTs in the health sector of developing countries: a framework paper”. Working paper no. 7 8. UNICEF (2005) Vietnam country profile: water, environment and sanitation. http://www.unicef.org/Vietnam_wes.pdf (accessed on 29 October 2010) 9. GAMOS Ltd (2005) Community television for the poor: a scoping study, final technical report 10. Vidanapathirana J, Abramson MJ, Forbes A, Fairley C “Mass media interventions for promoting HIV testing (review), The Cochrane Library 2009, issue 1 11. O’Donnell, O et al (2008) “Who pays for health care in Asia?”, Journal of Health Economics (27) p. 460 – 475 12. O’Donnell, O et al (2007) “The incidence of public spending on healthcare: comparative evidence from Asia”, World Bank Economic Review, 21 (1) p. 93 – 123 13. Brunei Times, “MOH preps DJs for health on the air”, March 25 2010 14. Hill AL, Rand DG, Nowak MA and Christakis NA “Emotions as infectious diseases in a large social network: the SISA model”, Proceedings of the Royal Society B, published online. http://christakis.med.harvard.edu/pdf/publications/articles/112. pdf (accessed on 29 October 2010) 15. Christakis NA and Fowler JH, “The collective dynamics of smoking in a large social network”, New England Journal of Medicine, 358 (21) May 2008. http://christakis.med.harvard.edu/pdf/publications/articles/084.pdf (accessed on 29 October 2010) 16. Channel News Asia, “Lose to win season 2 goes on larger scale”, 10 June 2010. http://www.channelnewsasia.com/stories/singaporelocalnews/view/1062407/1/. html (accessed on 29 October 2010) 17. Case DO (2007) Looking for information: a survey of research on information seeking, needs and behavior (2nd edition), London: Elsevier 18. InSTEDD. http://www.instedd.org (accessed on 29 October 2010) 19. Vasconcellos – Silva PR and Castiel LD (2009) “New self care technologies and the risk of self diagnosis through the internet”, Pan American Journal of Public Health 26 (2) p. 172 – 175. http://www.scielosp.org/pdf/rpsp/v26n2/10.pdf (accessed on 1 November 2010) 20. JPAL randomized evaluations in health. http://www.povertyactionlab. org/search/apachesolr_search?filters=type:evaluation%20sm_cck_field_ themes:Health (accessed on 29 October 2010)
23 | EMERGING TRENDS
It is obvious that reliance on ICTs for everything from keeping contact with family and friends, to checking bus schedules, to locating recipes will only increase in time, as the functionality of smartphones increases and as a greater percentage of the global population gains access to these devices. The following are key threats and challenges that must be properly managed to assure that trade and investment facilitation, energy security, and health systems will fully benefit from the region's growing reliance on ICTs.
in a position to use ICTs for coordination. This is especially pertinent in post-crisis situations. Relief efforts can be hampered when stakeholders’ efforts are not coordinated, resulting in oversupply in some areas and undersupply in others. Geographic information systems (GIS) mapping with distributed input capacity, like the PakReport mapping, is just one possibility for governments to ensure that public, private, and civil society organisations’ relief efforts do not work at cross purposes.
Governments’ coordination responsibilities
The rising wave of ICT devices inevitably leads to an engulfing tide of used equipment. The European Union alone is responsible for the annual generation of more than 8.5 million tonnes of waste electronics and electrical equipment,1 which also encompasses appliances like dryers and toasters. With countries like the ASEAN-10, rising incomes often translate into more frequent purchases of new devices which will eventually end up in landfills. A Thai report found that most PCs and mobile phones were discarded by survey respondents within three years.2 Some of this electronic waste (e-Waste) is properly recycled and more valuable components like gold, glass, and metals salvaged for reuse. However, despite the fact that the Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and their Disposal entered force in 1992, there are still large-scale violations and
One of the government’s main priorities in response to ICT deployment will be in coordinating the various actors to ensure that investments are wisely spent and that interoperability is maximised. Far from leaving the evolution of ICT to the market, the rise of eGovernment has shown that at a minimum, the government will be a major content provider using ICTs to improve transparency and transactional ease across a range of citizen-centred services. In this capacity, vertical (regional and national) and horizontal (inter-departmental) coordination will be essential to avoid the duplication of efforts across ministries and to streamline equipment procurement. In addition to coordinating the use of ICT, through local and international standard-setting protocols, governments are also
Huge business potential.
EMERGING TRENDS | 24
international shipments of electronic wastes that eventually up in unlined landfills with the potential to create environmental and public health risks. Japan’s Ministry of Environment, in conjunction with the Basel Convention Regional Centre for South-East Asia (BCRC-SEA), has supported ASEAN governments to inventorise electronic waste volumes and most countries have produced at least one publicly available inventory since 2007. The reports have found that workers involved in dismantling electronics and electrical equipment do not use safety gear like gloves or goggles, nor express interest in workplace safety.3 Additionally, individuals involved in the sale or repair of used electronic goods would not reveal to the Cambodian study team the names of companies involved in the import / export of electronic waste. Despite national laws in countries like Cambodia that prohibit the import of hazardous wastes, used electronic goods enter the country bound for second-hand markets, making it difficult to discern what is waste and what is simply "used". ICTs as distraction Governments must be wary not to put the cart before the horse and ensure that private activity is not crowded out by zealous publicly-driven programmes. ICTs in and of themselves do not erase the other social development problems that exist in a country; they may in fact worsen the situation if scarce funding is recklessly spent on programmes with little effect. What’s needed is rigorous evaluation of pilot programmes before they are scaled up, and a willingness to build on what’s there and being used already (e.g. radio and television broadcasts of public health messages). For all ICT projects, a focus on its intended benefits and outcomes, rather than the technology itself, will also help to clarify programme funding priorities, for example better rural electrification planning via GIS. ICTs are a medium, not an end. Digital security and privacy concerns With increasing security threats on the horizon, will Southeast Asian countries maintain the capacity needed to thwart security concerns? For example, several countries in the region have assembled Emergency Response Teams (ERT) which serve as ICT security watchdogs. They are responsible for issuing virus alerts and updates on possible security breaches. Three separate countries have been contacted for comments on the future of ICTs and the results were not promising; one issued an immediate bounce-back message since the destination inbox exceeded storage capacity and the two others resulted in time-out error messages. Without a doubt, there are people staffing these offices, as suggested by their frequently updated websites, but if the communication channels are only open one way, then they are in little position to preempt concerns that could grow in scale by acting on information obtained early on. Fulfulling that role is essential because ICTs store and
exchange sensitive financial data, e.g. mobile phones transmitting bank transfers between farmers. Risks of digital piracy for lower income populations are preeminent given their already precarious financial situation. Health data could also be misappropriated by cyber criminals if they hack into electronic health record systems. Everyone, but especially the poor, need protection from digital piracy. Fully staffed and operational government watchdogs must be set up in all countries to monitor and respond to cyber security threats. Literacy and connectivity Low literacy levels among those at the bottom of the pyramid mean that text-driven applications will remain underutilised. Voice-driven technologies are moving in the direction where illiteracy does not prevent a user from gaining benefits. Like Brunei’s health radio initiative, technology need not be complex to reach those with lower literacy and numeracy. Keeping technology simple, relevant and local should increase take up amongst potential users. Involving users in the design by demonstrating its benefit to frontline health workers and the poor, can also increase the likelihood of implementation success.4 It should not be taken for granted that just because a fancy ICT application is available in the village community centre, locals will gravitate towards using it unless the benefits are explicitly clear. Governments should also promote general ICT education across populations, and facilitate the translation of open source software into local languages.5
References 1. EMPA. 2010. “Ewasteguide.info.” Available at: http://ewasteguide.info/ weee-generated 2. Electrical and Electronics Institute. 2007. “Final Report – Development of E-Waste Inventory in Thailand.” Available at: http://www.basel.int/techmatters/e_ wastes/E-waste%20Inventory%20in%20Thailand.pdf 3. Cambodia Environmental Association. 2007. “Technical Report on National Inventory of Used EEE in Cambodia.” Available at: http://www.basel.int/ techmatters/e_wastes/report_cambodia_11-05-07.pdf 4. InfoDev (2007) “Improving health, connecting people: the role of ICTs in the health sector of developing countries: a framework paper”. Working paper no. 7. 5. UNESCAP (2009) Policy brief on ICT applications in the knowledge economy. Issue no. 7 December 2009. http://www.unescap.org/IDD/pubs/Policy_Brief_ No.7_-_December_2009.pdf (accessed on 1 November 2010)
25 | EDITORIAL TEAM
TRADE & INVESTMENT FACILITATION Darryl Jarvis is an Associate Professor at the LKY School of Public Policy. He specialises in risk analysis and the study of political and economic risk in Asia, including investment, regulatory and institutional risk analysis. He is an author and editor of several books and has contributed articles to leading international journals. He has been a consultant to various government bodies and business organisations, and for two years was a member of the investigating team and then chief researcher on the Building Institutional Capacity in Asia project commissioned by the Ministry of Finance, Japan. His current research is a large cross-national study of risk causality in four of Asia’s most dynamic industry sectors. He teaches courses on risk analysis, markets and international governance, and international political economy. His email is firstname.lastname@example.org Leong Ching is a PhD Candidate at the LKY School of Public Policy. Prior to joining the PhD programme, she received a MA (Journalism) from the University of London and worked in The Straits Times as an Assistant Editor before joining Channel NewsAsia as a Deputy Editor, where she anchored a “live” show on news and current affairs and secured several exclusive interviews, which included Minister Mentor Lee Kuan Yew and Indonesian President Abdurrahman Wahid. In 2008, she left to to pursue a full-time writing career and has written several books for private sector clients, government agencies and the ruling People’s Action Party. She continues to write widely on water issues in the mass media with articles in national newspapers, as well as specialised water journals. Her email is email@example.com
HEALTH SYSTEMS Phua Kai Hong is a tenured professor at the LKY School of Public Policy and formerly held a joint appointment as Associate Professor and Head, Health Services Research Unit in the Faculty of Medicine. He is frequently consulted by governments within the region and international organisations, including the Red Cross, UNESCAP, WHO and World Bank. He has lectured and published widely on policy issues of population aging, healthcare management and comparative health systems in the emerging economies of Asia. He is the current Chair of the Asia-Pacific Health Economics Network (APHEN), founder member of the Asian Health Systems Reform Network (DRAGONET), Editorial Advisory Board Member of Research in Healthcare Financial Management and an Associate Editor of the Singapore Economic Review. His email address is firstname.lastname@example.org Nicola Pocock is a research associate at the LKY School of Public Policy. Prior to joining the school, she worked as general manager at aidha, a financial education organisation that offers money management and entrepreneurship training for migrant domestic workers in Singapore. She was also a research volunteer at Amnesty International, has carried out social work in Marseille, France, and has done communication work for the Race Equality Unit in the UK civil service. Her research interests span health and social care issues, health systems financing, gender, migration and financial behaviours. Her email is email@example.com
ENERGY SECURITY Benjamin K. Sovacool is an Assistant Professor at the LKY School of Public Policy. He is also a Research Fellow in the Energy Governance Programme at the Centre on Asia and Globalisation. Dr Sovacool has worked as a researcher, professor, and consultant on issues pertaining to energy policy, the environment, and science and technology policy. He has served in advisory and research capacities at the U.S. National Science Foundation’s Electric Power Networks Efficiency and Security Programme, Virginia Tech Consortium on Energy Restructuring, Virginia Centre for Coal and Energy Research, New York State Energy Research and Development Authority, Oak Ridge National Laboratory, Semiconductor Materials and Equipment International, U.S. Department of Energy’s Climate Change Technology Programme, and the International Institute for Applied Systems and Analysis near Vienna, Austria. Dr Sovacool has published four books, more than 80 academic articles, and presented at more than 30 international conferences and symposia. His email address is firstname.lastname@example.org Anthony D’Agostino is a research associate at the Centre on Asia and Globalisation (CAG) with research interests in energy policy, climate change adaptation, and environmental decision analysis. Prior to joining CAG, Anthony worked with the Institute of Water Policy at the LKY School of Public Policy, using system dynamics to address public policy and water policy challenges. He has worked with the Greenhouse Gas Protocol at the World Resources Institute and at UNEP-ROAP, respectively focusing on corporate GHG emissions and sustainable buildings. In addition to consultation work on transportation and corporate environmental reporting, Anthony has worked for organisations in India, Australia, New Zealand, and the US on rural development and sustainable agriculture issues. His email is email@example.com and you can follow his work on the Southeast Asian energy sector on Twitter, @seasiaenergy.
The Lee Kuan Yew School of Public Policy is an autonomous, professional graduate school of the National University of Singapore. Its mission is to help educate and train the next generation of Asian policymakers and leaders, with the objective of raising the standards of governance throughout the region, improving the lives of its people and, in so doing, contribute to the transformation of Asia. For more details on the LKY School, please visit www.lkyspp.nus.edu.sg