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Understanding medical civil-military relationships within the humanitarian-development-peace ‘triple nexus’: a typology to enable effective discourse
  1. Simon Horne1,2 and
  2. S Boland3
  1. 1 Conflict and Health Research Group, King's College London, London, UK
  2. 2 Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
  3. 3 London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence to Simon Horne, Conflict and Health Research Group, King's College London, London WC2R 2LS, UK; simon.horne{at}


The interface between humanitarianism, development and peacebuilding is increasingly congested. Western foreign policies have shifted towards pro-active stabilisation agendae and so Civil-Military Relationships (CMRel) will inevitably be more frequent. Debate is hampered by lack of a common language or clear, mutually understood operational contexts to define such relationships. Often it may be easier to simply assume that military co-operation attempts are solely to ‘win hearts and minds’, rather than attempt to navigate the morass of different acronyms. In healthcare, such relationships are common and more complex - partly as health is seen as both an easy entry point for diplomacy and so is a priority for militaries, and because health is so critical to apolitical humanitarian responses. This paper identifies the characteristics of commonly described kinds of CMRel, and then derives a typology that describe them in functional groups as they apply to healthcare-related contexts (although it is likely to be far more widely applicable). Three broad classifications are described, and then mapped against 6 axes; the underlying military and civilian motivations, the level of the engagement (strategic to tactical), the relative stability of the geographical area, and finally the alignment between the civilian and military interests. A visual representation shows where different types may co-exist, and where they are likely to be more problematic. The model predicts two key areas where friction is likely; tactical interactions in highly unstable areas and in lower threat areas where independent military activity may undermine ongoing civilian programmes. The former is well described, supporting the typology. The latter is not and represents an ideal area for future study. In short, we describe an in-depth typology mapping the Civil-Military space in humanitarian and development contexts with a focus on healthcare, defining operational spaces and the identifying of areas of synergy and friction.

  • health services administration & management
  • medical ethics
  • public health
  • qualitative research

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The interface between humanitarianism, development and peacebuilding—the ‘triple nexus’—is challenging and contested, as the political search for long-term solutions abuts the humanitarian imperative for the apolitical relief of suffering.1 Western government foreign policy has shifted towards a proactive stabilisation agenda making the deployment of military assets in non-traditional roles (including health sector support and even development) increasingly common.

Meaningful debate over the use of these military assets in triple nexus contexts is hampered by the wide range of motivations for their deployment; the subsequent morass of acronyms and definitions can confuse all parties (potentially even the military) about what they are seeking to achieve. Indeed, the very choice of the term CMRel was necessitated by the fact that Civil-Military Relations (CMR) is already taken (describing a government’s interface with its own military) as are Civil-Military operations (CMO), coordination (CMCoord), cooperation (CIMIC) and even interactions (CMI)—all already being used by militaries and/or civilians to describe specific relationships and objectives. This lack of a standardised language generates confusion and makes ‘appropriate’ interactions harder, or may even prevent them entirely.

Typologies and frameworks have been attempted. Some are so broad they lack utility, for example, describing CMRel as the ‘issues that arise as civilian and military sectors negotiate their place in society and on the world stage’.2 Others such as the United Nations Office for the Coordination of Humanitarian Affairs’ (UN OCHA’s) ‘cooperation-co-existence’ spectrum fail to capture the range or complexity of situations where multiple civilian and military actors may operate concurrently.3 In other circumstances, specific terminology exists, but is not applicable to international triple nexus contexts.4

This paper derives a typology of relationships between civilian agencies and foreign/UN militaries. It uses medical CMRel to approach this important conversation, and there are several reasons for this. Humanitarian organisations and military medical units have the same origin in international humanitarian law (IHL), and therefore entertain similar legal protections and responsibilities.5 Importantly and contradictorily, medicine is also seen by governments interested in political influence and stabilisation as a mechanism for achieving just that, as health is often considered a supraordinate goal acceptable to all parties, and more generally as a ‘bridge to peace’.6 7 As a clear and broadly accepted example of CMRel on one hand, and a valuable political tool on the other, medical CMRel are likely to occur more frequently in the future. Most importantly, any typology capable of disentangling these motivations and complexities is likely applicable to CMRel more broadly, particularly other technical functions, such as engineering and logistics.

The typology is then used to highlight areas of likely CMRel tension. These are areas where further research and guidelines should be developed to clarify roles and responsibilities within CMRel, with a focus on providing effective relief to triple nexus-affected populations. It is hoped then that this typology will serve to stimulate productive dialogue between militaries and civilians about when and how to appropriately use military healthcare assets in aid, development and peacebuilding contexts.

Background and literature review

There are a number of motivations for the deployment of military forces to a triple nexus context. For example, many foreign governments adhere to variations of Fusion Theory or the Comprehensive Approach, which maintain that peace overseas enhances security at home, and can be achieved through a blend of security, political, financial and development tools.8 9 Adherents of these strategies believe that militaries can support many aspects of fragile states beyond simple peacekeeping; interventions which may result in CMRel. Meanwhile, for actors adhering to humanitarian principles of neutrality, impartiality and independence, there are legitimate concerns that CMRel unacceptably blur the line between agents with very different motivations. In extreme cases, this could bring physical harm to humanitarians, mistaken by belligerents for those supporting disputed political agendas.10

Despite these concerns, there are areas where CMRel are relatively uncontroversial. For example, few dispute the obligations of an occupying force to ensure the provision of aid to a conflict-affected civilian population, as enshrined in IHL.11 12 Similarly, military support to disaster relief efforts in peaceful regions is largely accepted by the international community, with clear guidelines for CMRel in these contexts.13 Domestic Civil-Military RELATIONS (a completely distinct area, between a military and its own government) are also widely described and generally accepted.

Other contexts generate significant disagreement and debate. For example, international guidelines exist for CMRel in complex humanitarian emergencies, where a humanitarian crisis occurs within an area suffering ‘total or considerable breakdown of authority resulting from internal or external conflict’.14 However, the practical implementation of these guidelines is often contentious, particularly provided the dynamic and unpredictable nature of these environments. Similarly, the role of CMRel in public health crises such as the 2013–2016 West Africa Ebola Epidemic remains undefined, as it is for military ‘hearts and minds’ activities (ie, those with an explicit counterinsurgency purpose) or military capacity-building which occurs alongside civilian development projects.15 16

Several authors have attempted generic CMRel typologies, but none is sufficiently and comprehensively workable for medical CMRel. For example, Seybolt describes a typology for military humanitarian interventions, based on the nature of intervention.17 Although relevant to the wider humanitarian context, Seybolt’s system does not span the breadth of triple nexus contexts. It also fails to consider the constituent components of militaries, which may include independently deployable corps that do not engage in offensive operations (such as health workers or engineers), with which civilian organs may selectively establish CMRel despite concerns about the wider military.5 UN OCHA describe a cooperation to coexistence spectrum and also outline appropriate CMRel according to the level of conflict; ranging from direct delivery of aid, to logistics support, to infrastructure support (the cookie-truck-bridge model).18 However, again this fails to capture the diversity and complexity of real-world motivations and contexts which underlie CMRel,19 20 perhaps explaining why awareness and implementation of these guidelines is limited on the ground.21 22

Method for typology development

The typology development followed five stages, influenced by Kluge23:

  1. Identification of the relevant partners to CMRel;

  2. Identification of the motivations for establishing CMRel;

  3. Defining ‘level of engagement’;

  4. Grouping of existing terms and analysis of empirical regularities between them;

  5. Development of a new analytic dimension, ‘alignment of interest’.

Several candidate analysis dimensions were drawn on after analysis of the existing literature. Table 1 shows examples of the main typological dimensions previously described in the wider CMRel literature and indicates those which have potential relevance to medical CMRel in triple nexus contexts.

Table 1

Existing typologies of relevance to CMRels

Partners to CMRel

Civilian actors

Host government departments, foreign government agencies, international organisations (IOs), UN organisations and local, national and international non-governmental organisations (NGOs) may all engage with militaries in a triple nexus context.

Humanitarian organisations focus on access to affected communities and the apolitical delivery of relief in an emergency context. These goals are circumstantially dependent on the humanitarian organisation’s adherence to core humanitarian principles, including neutrality, impartiality and independence. This is particularly true in contexts where trust between affected communities and government or other politically aligned groups is limited. Necessarily, this requires that humanitarian agencies maintain a position that is discrete from actors with political or perceived political interests. However, while ideological adherence to humanitarian principles may be considered paramount to some humanitarian organisations regardless of context, the functional utility of this adherence is less immediate in environments where trust between communities and political actors is robust.

Development agencies—which includes NGOs, IOs, UN organisations and government departments—may have similar concerns, and may at times choose to partially align with humanitarian principles according to the context. However, if the context permits, and if doing so would improve the efficiency or efficacy of development project implementation, these agencies may also choose to act with a cooperative or collegiate approach to a wider array of stakeholders, and have more of a focus on stabilisation or even peacebuilding and prosperity agendas. At times, this may include relationships with politically aligned actors, including militaries.

Military forces

Historically, militaries have often established CMRel to generate support from a conflict-affected civilian population, often referred to as the ‘hearts and minds’ strategy. This may be done to access certain areas unopposed, to gain mission-critical intelligence from friendly populations, or to better ensure the safety of military personnel during tactical operations.

In a triple nexus context, militaries’ combatant units can support humanitarian activities by improving or helping provide security to civilian agencies. The most obvious example is military support to peacekeeping operations, or in the provision of military escorts to civilian convoys. A military may also undertake a non-security secondary role as a source of generic manpower, for example, by helping to remove debris or delivering aid following a natural disaster.

Many might perceive militaries as homogenous groups, as they all represent a physical manifestation of a foreign policy. However, within any military there are groups with different specialisms, constraints or objectives. The degree to which these constituent groups hold a military nature can differ significantly from the wider military body, including in the relationships the groups have with civilian populations.20 For example, in the UK’s military, medical services (excluding veterinary services) and chaplains are legally non-combatant as defined by the Geneva conventions; they do not engage in ‘hostile acts…on behalf of a party to the conflict’.24 Medical groups also have professional and ethical codes that may take precedence over their military obligations, and as a result, these groups may merit or seek a different relationship with civilian actors and affected populations.

Importantly, in some militaries, these groups can also be deployed independent of combatant groups. For example, the UK commitment to the 2013–2016 West Africa Ebola Epidemic response largely involved support troops. In addition to medical groups, other technical professions within a military might aspire to a closer CMRel than their ‘teeth-arm’ (frontline combat troops) counterparts, such as engineering, logistics, stabilisation, coordination, political and civil affairs, and analysis personnel.

Non-state armed groups

The typology was not designed to include relationships with non-state armed groups (NSAGs). However, as NSAGs become increasingly organised, politically competent and media aware, they often recognise the imperative to provide functions of the state they are seeking to replace or augment. It is conceivable therefore that many of the influence, political and capacity building interests demonstrated by foreign militaries may in fact be shared by NSAGs. Thus, the typology may provide a reasonable starting framework for relationships between these groups and civilian agencies as well.

Potential motivations for establishing medical CMRel


Humanitarian groups are generally clear about their motivations for interacting with the military, whether that is simply to protect and promote humanitarian principles, avoid competition, minimise inconsistency or, when appropriate, to pursue common goals.25 At a strategic level, the promotion of the humanitarian agenda can be seen as influence, for example, when the international president of Médicins sans Frontières (MSF) presented to the UN Security Council in 2016.26

The motivations for a military or a state-sponsored civilian organisation entering a CMRel may be more variable.27 These include generic political influence; bettering national security through regional stability, alliances and interoperability; improving resilience through development; realising a humanitarian imperative; affecting public perception at home; or meeting a professional obligation.

Social perception

Social perceptions that drive domestic political and social agendas may also be at play, as an ethical government response to human suffering is perceived to be of paramount importance to populations and voters at home. For example, while the deployment of the UK military to a disaster is almost invariably undertaken at the request of the Department for International Development (DfID), it can also be requested by the Foreign and Commonwealth Office (FCO) if DfID does not deem a military-aided response justifiable from a purely humanitarian perspective.28 This allows military deployment to areas affected by natural events to demonstrate support, rather than because humanitarian relief is necessarily needed. The UK military response to Hurricane Irma in the British Virgin Islands is a useful example.

Social perception is not mentioned as a driver in the literature around such CMRels, but logically falls as a subset of influence.

Positive health outcomes

Achieving positive health outcomes in triple nexus-affected areas may also be a genuine military motivation, at least inasmuch as health risks in less resilient countries have recognised risks for the security of other countries. Infectious disease outbreaks are the most obvious example, with same-day global travel and long incubation periods for dangerous disease—up to 21 days for Ebola, for example—the concept of quarantine has become untenable, as diseases can move faster than contacts can be identified or international borders can close.

Initiatives such as the Global Health Security Agenda (GHSA) and Global Health Security Alliance sprang from this realisation. These initiatives focus on building capacity to detect and manage potential public health emergencies of international concern at their source by supporting affected nations under the International Health Regulations.29

Some might argue that this capacity building serves to secure the Western world more that it supports health development in the host nation. For example, the GHSA and others recognise that improved health is also linked to a reduction in conflict, as well as improvement in economic and other development indices, with positive knock-on effects to high-income countries29 30:

Healthier populations make for more prosperous and stable societies. When the United States helps improve the health of people in other countries, Americans gain goodwill and strengthen US national security.31

However, while other motivations are made explicit (and are perhaps referenced to gain broader political support in legislative bodies), the motivation is still health-based in real and meaningful ways.32

In addition, militaries often have access to areas of healthcare (eg, those provided by host-nation militaries) that are less available to civilian organisations. In some countries, this sector is sizeable. In Pakistan, for example, it is estimated that 10 million people access their healthcare through the military.33

Professional obligations

Perhaps unique to military medical elements are professional obligations placed on healthcare workers (HCW). Many medical systems require doctors to improve their knowledge and clinical skills, to seek excellence in clinical care and delivery and to aspire to medical best practice.34 Understanding ‘best practice’ requires knowledge sharing within the medical community, including the civilian medical community.

However, these technical aspects are not the only areas of military medical professional obligations. Importantly, there are also extensive duties to the patient and to other HCW. In many countries and areas, these are clearly described ethical duties, and include compassion and altruism, which are motivations aligned closely with a humanitarian rationale. Indeed, it is important to note that military HCW are granted the same protections under the first Geneva Convention.

Critically, these professional obligations are not voluntary. To use the UK as an example once more, the UK General Medical Council is clear that a HCW is ‘personally accountable for ( their ) professional practice and must always be prepared to justify ( their ) decisions and actions’.35 While the challenges of dual loyalties for military medical personnel are well described, UK Military Medical Officers are explicitly ‘doctors first’, and many believe this should hold true worldwide.36 37 While other technical functions do not have such clearly defined professional obligations, other groups supporting healthcare delivery (eg, logistics and engineering corps involved in healthcare facility construction or medical supply chains) are arguably also captured by these obligations.

Professional obligations are not described in the literature as key motivations for CMR—perhaps because on an organisational or state level, personal obligations are unlikely to be important. They are however likely to be drivers for many of the personal interactions that occur ‘on the ground’. As they result from a fundamental desire to see a health benefit, this group is included under ‘positive health outcomes’.

Humanitarian imperative

As a motivation for establishing CMRel, disaster relief overlaps with positive health outcomes, but may also appear to meet the humanitarian imperative of saving lives and relieving suffering. On occasion, the military may be doing this at the direct request of a humanitarian agency or affected-country government (as in the 2013–2016 West Africa Ebola Epidemic), and so might be considered a genuine part of a foundationally humanitarian response.30

Grouping existing terms: the basic typology

Terms in common use were grouped, with key factors relevant to the above dimensions highlighted. Each group was given a type, iteratively derived from the individual terms.

Military-led Civil-Military Coordination

Military-led Civil-Military Coordination (CIMIC) primarily serves military and/or national security objectives, and so includes information and intelligence gathering, access permissions and other ‘hearts and minds’ activities. CIMIC activities may also serve secondary purposes, such as relief activities.

CIMIC CMRel are specifically between a military and a civilian agency or community and are widely described. Key examples include the USA’s Civil-Military Operations (CMO), North Atlantic Treaty Organization’s (NATO’s) CIMIC and Canada’s Civil-Military Cooperation (CIMIC/COCIM).38–40

Defence engagement (DE) is defined by a focus on national influence and security through overseas capacity-building and conflict prevention.41 As with CIMIC, DE does not preclude benefit to other agencies or populations, but these are generally secondary effects. DE also prefers military-to-military relationships, although civil-military interactions are explicitly encompassed in the doctrine.

Doctrinally, these CMRel historically sat predominantly at the tactical level (such as the Medical Civic Action Programme in Vietnam42), although recent changing doctrine has seen a greater role at the operational level. The exception is DE, which started at the strategic and operational levels and has far less application at the tactical level.

Civil-Military Healthcare Engagement

Civil-Military Healthcare Engagement (CMHE) includes CMRels that emphasise health benefits as a primary outcome. Motivations for CMHE can range from ensuring health security at home, to an altruistic interest in improved global health generally, to targeted humanitarian-like interests in securing the health of a triple nexus-affected population.43 Improved host nation health is a specified objective of CMHE, regardless of other motivations.

A predominantly civilian-led example of CMHE are Global Health Security initiatives, including the GHSA. More military-focussed example is the USA’s Global Health Engagement. As noted above, UK Defence Healthcare Engagement (DHE) is technically DE activity carried out by a medical unit. However, given DHE’s inevitable health focus and an increasingly nuanced approach to capacity building, it is better accommodated within CMHE.44

These CMRel sit predominantly at the strategic and operational levels.

Civilian-led Civil-Military Coordination

Civilian-led Civil-Military Coordination (C-CMC) emphasises the primacy of civilian objectives and leadership, and includes IHL, international humanitarian disaster relief law (IDRL) and UN CMCoord. As such, they cover the entire spectrum from international strategies to manage health risks, thorough operational relationships in disaster zones, down to the interaction between force elements and civilian agencies on the ground.

Common CMRels are shown at Table 2, grouped according to the above types. Characteristics from within each CMRel’s definition are highlighted to illustrate how they fit into that type.

Table 2

Examples of commonly described CMRels and relevant extracts from their definitions, grouped according to overarching type

The level of engagement

The level of engagement ranges from strategic interests and effects, through the operational level, to tactical ‘on the ground’ impacts. While most militaries have a shared understanding of these terms, civilian meanings often differ. For the purposes of this analysis, the UN description is used, whereby ‘strategic’ refers to international-level work, ‘operational’ refers to work at the country-level or cross-sectoral areas within a country and ‘tactical’ refers to district-level work or work in an individual technical area (ie, a single cluster).45 This description has sufficient overlap with the military definitions that it provides a workable framework for CMRel discussions.

Predominantly strategic CMRel include DE, where activity short of the application of force is undertaken by a military to increase their nation’s influence.46 This influence may eventually support national interests through treaties or trade agreements. From a civilian perspective, these strategic CMRel would include advocacy for respect of IHL on the international stage.

The operational level focuses on enabling activities such as interoperability and coordination. From a civilian perspective, an excellent example would be the UN OCHA Civil-Military Coordination Field Handbook, which describes how a coordinated CMRel is established and functions in country, especially after natural disasters. In terms of military terminologies, this would be well described by the USA’s Department of Defense concept of CMO, where the outcome is defined in terms of US objectives for host nation or regional security.38 UK DE has recently developed to include specific activities not normally considered ‘influence related’, such as capacity building and conflict prevention, and so also includes operational-level interventions.47 DHE, by definition, serves the same purposes, and is undertaken by a medical unit within the health sector.48

At a tactical level, interactions with local people might result in information and intelligence being shared with militaries, or by improving a military’s freedom of movement in difficult-to-access areas. This fits Civil-Military Cooperation (CIMIC) as defined by NATO, where the purpose of CMRel interaction is ‘in support of the mission’.48 It also describes the IHL duties of an occupying forces to ensure aid provision (even, in extremis, by direct delivery) to a civilian population in wartime.

The key types from Table 2 can now be mapped against the level at which the activity is most commonly seen (strategic to tactical) to generate Figure 1.

Figure 1

Civil-Military Relationships (CMRel) types mapped against objectives and level of activity (strategic to tactical). CMR, Civil-Military Relations; DE, defence engagement; DHE, Defence Healthcare Engagement; HS, Global Health Security; IHL, international humanitarian law.

Gauging the value: alignment of interest as a new dimension

A simple description of CMRel types is of academic interest but attaches no sense of value to the CMRel. Given the controversies and debate around CMRel, any typology should attempt to convey some sense of which relationships might be beneficial and which have the potential to be contested or difficult.

UN OCHA believes the appropriate degree of CMO is largely determined by the degree of the affected area’s physical conflict.18 25 CMRel defined as such may only require coexistence, which means nothing more than deconflicting activities and ensuring protected sites can be appropriately safeguarded under IHL where there is active conflict. This is usually advocated in contexts where any degree of humanitarian activity associated with a perceived party to the conflict may threaten a humanitarian organisation’s perceived neutrality.

However, while this guidance concentrates on level of conflict—contrasting peacetime disaster relief with complex emergencies (where conflict is an integral part of the context)—alignment of interest might be a more appropriate description.13 49 This is because low levels of an affected populations’ trust or engagement with military personnel or bodies does not only arise during conflict settings.

Furthermore, ubiquitous access to the internet and media means that neutrality is not simply a matter of not taking sides in a conflict. Effective neutrality requires total disassociation from political agendas, but activities are increasingly identified as politically motivated even when all efforts have been made to avoid association. The recent attacks on the MSF Ebola treatment facilities in the ongoing DRC Ebola outbreak are cogent and worrying examples, as are a number of attacks on other humanitarian agencies by terrorist organisations in recent years.50 Development activities in particular are often closely associated with donor government political objectives, and so even in ostensibly peaceful or non-conflict areas, CMRel might imply affiliation and shared political motives between humanitarian and civilian actors, militaries and governments.

Throughout the above examples, it is tacitly assumed that the relationship will be negative and therefore requires constraining, and this is undoubtedly often the case. However, there are clear examples of CMRels that should not be problematic and have resulted in significant synergies that existing dialogue does not consider, including operational planning on integrated UN missions.51 Furthermore, in UN OCHA guidance regarding permissive conditions where there is no violent conflict, civil-military cooperation is used to capture an expansive and inclusive range of CMRel. This might include information sharing, or task allocations that maximise the effect of resources, limit competition and otherwise facilitate synergies. This is frequently advocated in peacetime natural disaster responses. Equally, in some conflict settings, military personnel or bodies may be more trusted than other groups or agencies, particularly in their ability to provide not only relief but also protection. In these situations, common interest between militaries and affected populations may reflect a dimension whereby CMRel can make valuable and positive contributions, rather than acting as a tool to merely avoid negative impacts.

Thus, ‘alignment of interest’ (which may be positive, neutral or negative) must be considered as an additional dimension. Three elements appear to impact ‘alignment of interest’, and so on the positive or negative potential of the CMRel, those being purpose, proximity and perception.


If all agencies involved in CMRel share a broadly common set of objectives (such as providing life-saving aid to a disaster-afflicted community), it is possible that there will be significant synergies, as long as the relationship is managed effectively. This is probably also true when purposes diverge by degree, as long as they are believed to be broadly aligned, for example, genuine capacity-building interests or improving basic population health. In contrast, where one activity seeks to improve health, and the other simply provides an excuse for a foreign military to undertake overseas training, there is likely to be a degree of friction. A similar distinction has been couched as ‘complimentary or competitive goals’.52 Critically, shared goals between civilian and military actors are not enough. What matters is the degree to which the affected population (or other local armed/political actors) value those same goals.


The closer the physical proximity of civilian and military actors to the supported community, the more pronounced the effects of differences of purpose. If a military is building a school in one state to facilitate access to political leaders, while in another an NGO is building to meet a humanitarian need, the friction generated by the two activities will be less pronounced than if they were in adjacent villages. Similarly, the relationship will be far more constrained when both actors are side by side in a fragile state, compared with when they meet at an international conference setting strategic priorities. Tactical interactions will always be higher risk and more challenging than strategic ones.

The political reach of foreign militaries (and their distinct networks) may also make strategic interactions more productive, through perspectives, academic approaches, equipment, resources capabilities and even stakeholders different from those typically encountered by humanitarians.


The humanitarian principles of neutrality, independence and impartiality serve the important practical purpose of facilitating access to populations that are distrustful of other groups’ motives for providing aid. Any actions that erode them may harm their operations or even place them at risk. For this reason, the principle of ‘distinction’ between civilian and military bodies has been increasingly relevant in triple nexus contexts where militaries and civilians are situated in complex, highly charged environments full of conflicting narratives and agendas. The Inter-agency Standing Committee guidelines state that militaries should wear uniform and drive military-marked vehicles to make them visibly distinct from civilians for exactly this reason.53

Distinction may also be important for militaries, in that a visible uniformed presence contributing to the development of a sector may support the military’s influence objectives abroad, and could aid in bringing budgetary and popular support at home.

A combination of purpose, proximity and perception allows for the identification of areas where CMRel may be particularly problematic or beneficial. Therefore, ‘alignment of interest’ is a more relevant analytic basis for establishing the degree and scale of CMRel, rather than level of conflict.

Establishing a new CMRel typology

Based on identified partners, underlying motivations in the grouping of terms in common use and the ‘alignment of interest’ dimension, CMRel can be mapped onto the following six axes:

  1. The civilian health objective (humanitarian relief vs development, capacity building, and risk reduction);

  2. The military objectives for intervention;

  3. The relevant levels of engagement (strategic, operational, or tactical);

  4. The relative stability of the area where the CMRel is taking place (area context);

  5. The grouped terms that are mapped against the above four axes;

  6. The alignment of civilian and military interest (drawn from purpose, proximity and perception) that exists in these spaces.

Overlaying these dimensions generates six discrete operational spaces (Figure 2). The potential risk associated with CMRel can then be judged to be high (red), intermediate (amber) or low (green). In high-risk areas, synergistic CMRel are still possible, but there are likely to be several barriers which mean that damaging CMRel are more likely to occur and may be significantly detrimental. Equally, in green areas, harmful CMRel may still occur, but the conditions are such that if well managed, positive relationships are more likely.

Figure 2

Typology of Civil-Military Relationships (CMRel) according to health objective, military objective and conflict of interest. CMHE, Civil-Military Healthcare Engagement.

Evaluating fit of existing terms mapped against these axes

Overall, the typology appears internally consistent, in that the definitions of the terms match each situation described by the various axes. As such, it should allow a common terminology to help structure discourse about CMRel. Initial analysis also suggests the model has some external validity, as the highest-risk areas predicted by the typology align closely with those already observed and described in the literature. Targeted research in other contexts will be needed to validate the typology as a predictor of beneficial and problematic areas for CMRel.


CMRel will become increasingly common as governments attempt to extend their influence and enhance their security, using all the means at their disposal, including medical units. Effective debate about what defines appropriate use of these capabilities is hampered by the range of motivations and operational parameters behind them, and worsened by a vast array of similar and overlapping terminologies and acronyms. This typology allows the various CMRel to be effectively grouped, in a way that is comprehensible to both civilian and military policymakers. The addition of the ‘alignment of interest’ dimension further elevates the typology from a simple categorical description into a potential tool to predict the risks and benefits of CMRel in a given context.



  • Twitter @Triagemonkey

  • Contributors Both authors contributed equally to the research and authorship of the paper.

  • Funding No funding was received for this research

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Data availability statement Data sharing not applicable as no datasets generated and/or analysed for this study. No additional data are available.

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