Defence healthcare engagement

Defence engagement activities can occur across the spectrum of conflict from health systems strengthening as part of preventing conflict, during conflict to maximise the effectiveness of the health system of allies and partners, and after conflict to support the creation of security and stability.4 Healthcare to non-military beneficiaries is a key deliverable for the security services in many emerging and low-income countries, a situation that is less common among high-income countries. Therefore, defence healthcare engagement may contribute to building the conversation about wider development of the whole health sector in an overseas country. This can contribute to wider UK national goals in global health.5 Thus, the nature of capacity building in health services created by defence healthcare engagement through the security sector can contribute to wider strategic policy objectives in the diplomatic and economic instruments of national power beyond purely military policy objectives.6

Defence healthcare engagement needs to build on previous experience and lessons learnt. In Afghanistan, the UK initially delivered first aid training for Afghan National Army and Afghan National Police personnel in Helmand.7 However, the key transformation occurred when NATO supported the requirement for the Afghan 205 Corps in Helmand to have a regional-level referral hospital in which to admit their security forces casualties after NATO forces departed from Helmand. The last 18 months of the UK campaign in Helmand required a medical mentoring programme to enable the Afghan army hospital in Camp Shorabak to deliver this medical capability. While ultimately successful, there was difficulty in maintaining a programme of mentoring and partnership across each operational rotation because of the lack of institutional knowledge in this field.8

The DMS contribution to the Ebola response in Sierra Leone is also another example.9 In the first phase, the DMS supported the surge of indigenous healthcare capacity by running training programmes for the use of personal protective equipment by healthcare workers. In the second phase, medical support contributed to the moral component of the international response by providing access to international quality healthcare services for both Ebola, and disease and non-battle injury. Transition to indigenous capacity was based on handing over the military Ebola treatment unit to the civilian sector and using DMS skills to support the development of the Royal Sierra Leonean Armed Forces rapid deployable infectious disease capability.

However, this narrative of short-term reactive engagement by international military medical staff with local military and civilian actors is insufficient to capture the challenges of persistent and long-term partnerships for capacity building. Instead, a more sophisticated narrative focusing on the unique role of DMS in contributing to the development of partner security services medical services is beginning to emerge. This may include police and prison services as well as armies. There are no other international agencies or non-government organisations (NGOs) for which this segment of a national health sector is a natural focus of capacity-building activities. This emphasis can contribute directly to the stabilisation effect of creating indigenous security capacity for peace making and peace keeping. Contemporary instability and conflicts in emerging and low-income countries are increasingly being managed or supported by local and regional security sector forces. Therefore, the DMS also needs to consider how to support military medical capacity building at a regional level using our experiences of working within coalitions and alliances. Finance for security sector health services usually come out of the Defence Ministry budget, which tends to be disproportionately great during periods of tension in security, and therefore the DMS can have an indirect effect on raising quality across the local health sector but without actually having an effect in ‘humanitarian space’.10

There are potential philosophical issues associated with the use of international military medical services in the civilian health sector. Most high-income military medical services recognise the concept of humanitarian space and the importance of a clear distinction between military forces and civilian healthcare providers or NGOs in complex emergencies. It is, therefore, essential that DMS engagement in the health space is sensitive to the local political situation and should respect the importance of separating the civilian health sector from security-related issues. Although the concept for stabilisation operations includes the provision of basic services as a critical component to building consent for the contested support of the civilian population, care is needed to make sure that civilian health services themselves do not become an instrument in the conflict. There is a need for deep conceptual recognition of these issues by all actors in the health and humanitarian space. The salient totemic issue surrounds the use of international military forces to provide direct, non-urgent medical care with the civilian population (MEDCAPS),11 This needs approaching with sensitivity and only as an agent of last resort.12

The DMS needs to ensure that our people are provided with appropriate ethical and cultural frameworks. In the hospital in Camp Bastion, it was necessary to adjust the clinical intention for Afghan casualties compared with Western European and NATO casualties.13 As a practical example, it might have been correct to make an early decision for amputation for an Afghan with a severe lower limb injury rather than considering a long programme of limb reconstruction that might be possible for a British casualty. The most challenging aspects may lie within local nursing cultures. In many healthcare systems, nurses have no role in personal care for patients as that is done by relatives. Yet in the security sector, there are no relatives available to look after patients, so it may be necessary to have some challenging discussions with nurses to remind them of their duties in terms of provision of personal care for patients who cannot do this for themselves. There may also be challenges with the standard of nursing observations and records. Thus, we may have to sensitise our people to some of the realities of caring for patients in a resource-constrained environment at a level that they will not have experienced in the UK. It can be very distressing to watch somebody die of a condition that you are perfectly competent to care for yourself but for which local clinical staff may not have the tools, techniques or equipment to treat themselves.

The centre for defence healthcare engagement

In light of the changing nature of conflict, the humanitarian space and the rapid rise of the security sector in delivering health in many emerging and low-income countries, the DMS needs greater capability and capacity in teaching and learning about global health. The CDHE is the start of an approach aimed at networking knowledge, capability and capacity in global health between security and civilian sectors. It will help the DMS to build a cadre of people who have a professional interest in this field to provide a system-level perspective on healthcare engagement with overseas security sectors. This will set a more strategic approach to global health within the Armed Services and between the security sector, civilian domestic and international partners. The UK is unique as there are no military hospitals. However, there are close relationships between the NHS and the DMS to coordinate hospital care for armed forces personnel. It may be possible to use this collaboration as part of the defence healthcare engagement proposition both in the UK and in the country of engagement. Part of this effort might be to facilitate and signpost some of the very high-quality, internationally recognised, civilian health sector education systems that we have in the UK. The goal is to match the range of tools that the UK has available against the range of needs that are present in a partner country and focusing our national tools to those needs that are going to have the greatest strategic impact.

DE is a core task for the DMS, and therefore we need to embed the skills to deliver it as part of core activity and core knowledge. There are some basic principles and skills that need to be part of the military medical education system. The DMS also needs to look at the deeper educational needs for people who are going to lead and manage the approach. The CDHE will look at where that knowledge is held and how it is communicated just as would be done with any other technical aspect in medicine. The DMS Military Humanitarian and Stabilisation Operations Course provides specific generalist education in this field. Above this level, the CDHE will examine the methods for postgraduate education and advanced ‘clinical experience’ in this field so a small number of people will have the opportunity to develop Defence Engagement as an additional career field.

The investment into the CDHE needs to be underpinned by the development of performance measures and measures of effectiveness. Some of these will be soft, but then many of the foreign policy objectives under which we may operate are very difficult to measure. It is also possible to have some hard targets. As a practical example, in our engagement with Pakistan, our unique contribution could be about contributing to their internal debate about the role of nurses. This is exactly the theme of a recent report on how investing in nursing will improve health, improve gender equality and support economic growth.14 The Pakistan military medical services has also developed an employment pathway for ‘Female Doctors’ in response to the large number of female graduates from medical schools. The DMS engagement programme can also support the role of women in the delivery of healthcare in the Armed Forces medical system. The DMS impact on the Armed Forces medical system can be extrapolated into a ‘change agent’ role in the wider Pakistan health sector. Thus, defence health engagement can have a role to play in wider upstream capacity building because of the relatively non-contentious nature of military medicine compared with other military activities.