• education & training (see medical education & training)
• international health services
• qualitative research
• quality in health care

The Academic Centre for Defence Healthcare Engagement (ACDHE) has a remit to evaluate and improve defence healthcare engagement (DHE) activities. DHE is the use of military medical capabilities to achieve Defence Engagement effects (prevent conflict, build stability and gain influence) in the health sector. 1 2 Short medical courses (SMCs) are commonly used as ‘off-the-shelf’ DHE solutions, but there has been little in terms of assessment of their efficacy. Given DE is based on a long-term view and has no end-state,3 we looked for progression of a country’s engagement in SMC as a potential measure of successful DHE by interrogating the Enhanced Security Cooperation Activity Plan Application for Defence Engagement database from 2016 to 2020. Progression included, for example, attending as an observer first, then sending students, then selecting instructors or even running their own version of the course. We also reviewed postcourse reports for insights about the effectiveness of SMC.

Twenty-one countries attended a total of 72 SMCs. Thirteen courses were delivered in six Partner Nations (PN), while 49 UK-based courses were attended by PN students (46) or observers (13). Disappointingly, nine countries (43%) did not engage further with the SMC, while three countries attended different courses instead. Eleven of these ‘failures to progress’ were priority countries for Defence.4 Of the 57% with ongoing engagement, progression varied. One country now runs its own version of the SMC and two others are close, all with ongoing UK engagement through regular faculty contributions. Conversely, two other priority PNs, accounting for 42% of all SMC attendances, keep attending without the relationship progressing. Helping us understand this spectrum of outcomes, the postcourse evaluations suggest the following themes are associated with developing relationships: clear PN objectives, similar UK and PN healthcare systems, similarity of healthcare culture (eg, familiarity with medical simulation and human factors concepts), shared language and appropriate student selection.

Clearly our understanding of the value of SMCs remains incomplete. Not all SMCs are entered in the national DE database,5 and we applied a very narrow measure of effectiveness (SMC development) and so would miss wider influence or economic impacts. However, these results reinforce a dawning realisation in DE that such activities can be highly effective but only if they meet the PN needs. If the PN has a clear plan for how the SMC fits into their development, sends appropriate personnel, has a health system and practice culture similar enough to the UK model that they can apply elements of the course, and language barriers are effectively mitigated, they clearly find them valuable. In contrast, some PNs are interested enough in SMCs to continue trying, but do not progress to more mature engagements—DHE ‘missed opportunities’. Critically, many engagements fail to progress at all, often for predictable and avoidable reasons. Better understanding of the PN context, rationale for engagement and adjustment of course delivery might achieve greater progression of SMC DHE relationships, thereby improving impact and reducing costs.

This is the first systematic evaluation of the impact of UK DHE activities and shows ACDHE taking its first steps in delivering enhanced strategic effect. By applying the same rigorous governance principles to DE that it does to any other clinical endeavour, the Defence Medical Services will continue to support UK strategic interests in the most cost-effective manner possible.