Civil-Military Interface Lessons Learnt

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Civil-Military Interface Lessons Learnt

• Chair and Keynote Speaker Brig Robin Cordell
• Co-chair Maj Gen Nunes Marques, MD

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Civil-Military Interface Lessons Learnt
1400 - 1530 Civil-Military Interface Lessons
Learnt Chair and Keynote Speaker Brig Robin
Cordell Co-chair Maj Gen Nunes Marques,
MD Governance, Reconstruction and
Development Brig Robin Cordell Evolvement of
Civil-military Relationship Concept in Nato
Requirements for Medical Cooperation in the Field
of Reconstruction and Development Col Zoltan
Vekerdi, MD Migrants Health New
Challenges Prof Istvan Szilard
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Civil-Military Interface Lessons Learnt
1530 - 1600 Coffee 1600 - 1730h Civil-Milit
ary Interface Lessons Learnt Chair and Keynote
Speaker Brig Robin Cordell Co-chair Maj Gen
Nunes Marques, MD CIMIR or CIMIC, Time to End
the Humanitarian Confusion? Knut Ole Sundnes,
MD Title to be announced Col José Donato Ramos,
MD Discussion Panel
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Governance, Reconstruction and Development
(G,RD)

• Brigadier Robin Cordell
• BSc MB BS MRCGP MFOM DCH DRCOG
• Allied Command Operations Medical Advisor
• Supreme Headquarters Allied Powers Europe
• B7010 SHAPE, Belgium
• robin.cordell_at_shape.nato.int

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Format of the presentation

• Who we are and what we do
• Definitions
• Why this issue is important
• What we intend to do about it
• How we will know we have achieved our aim

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ALLIED COMMAND OPERATIONS (ACO)
NATO HQ (Brussels)
Military Committee
COMEDS
Allied Command Transformation
CO-OPERATION AS THE IMPERATIVE
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Medical Support in the Joint Operational
Environment
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MEDICAL SUPPORT TO MARITIME OPERATIONS

• Maritime operations
• Littoral operations

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Definitions and context
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Stabilisation

• Stabilisation is the transition phase between the
  conclusion of kinetic military operations and the
  implementation of long term governance,
  reconstruction and development activity.
• Health outcomes are poor in fragile states and
  there is consensus that health sector
  strengthening can assist in state-building

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G,RD Operational Planning Model
Inform
Cultural Affairs
Needs of the District
Define
Deliver
Patrols
Health
HTTs
RD
Coalition
ANA Lead
PRT Lead
CLEAR
BUILD
HOLD
SHAPE
Local Economy
ANA Lead
ANP
ANP
HUMINT
Education
Humanitarian Aid
Governance
Religious Affairs
Tipping Point for Population Support
Pervasive ANSF-Led ISAF Enabled Information
Operations Campaign
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Civil-military co-operation

• The co-ordination and co-operation, in support of
  the mission, between the NATO military command
  and civil actors, including the national
  population and local authorities, as well as
  international (IOs), national and
  non-governmental organisations (NGOs) and other
  agencies. IOs and NGOs will prefer the term
  co-ordination, as this is more neutral.

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Fragile states

• Those nations in which the population is at risk
  through impending or actual collapse of the
  economy and essential services, including a lack
  of infrastructure to support health.

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Governance

• The process of decision making by a responsible
  body, incorporating consistent management,
  cohesive policies, processes and the appropriate
  delegation of decision rights for a given area of
  responsibility, in the interests of those for
  whom the body is responsible and accountable to.

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Reconstruction

• Includes the provision of emergency
  infrastructure, essential government services,
  rebuilding, and relief to prevent or ameliorate
  humanitarian emergency, in order to enable the
  local population and institutions to restart and
  establish viable normal activities. This activity
  is principally a civilian lead, including
  planning and resource implications.

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Development

• Intervention to support improvement in the
  provision of essential services in a community or
  a nation, through building sustainable capacity.

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Health Sector DevelopmentIn Afghanistan
Health - 3 of GIRoA operating budget and 5 of
the development budget Education - 20 of GIRoA
operating budget and 9 of the development budget
60 of the funding for the health sector comes
from external sources - World Bank, USAID and EC
ANDS (MDGS)
HNSS
Implementing SOPs
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Afghan Health Service
Essential Package of Hospital Services
Basic Package of Health Services
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Why is this issue important?

• Incoherence of military medical engagement (in
  Afghanistan and also in Kosovo)
• Importance to stabilisation efforts
• Importance to NATO Medical Capacity
• Ethical Issues
• Problems with MEDCAPS
• Medical Engagement (Medical Outreach)
• Optimal placement of health advisors
• Need for guidance and training of our people

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Humanitarian assistance, development and security
sector reform
Humanitarian assistance (emergencies)
Development of the civil healthcare system
Development of the military healthcare system
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ISAF medics saving lives in Sangin
24 Mar. 2009PR 2009-280
KABUL, Afghanistan - International Security
Assistance Force (ISAF) medics at the Regimental
Aid Post in the Sangin area of northern Helmand
province provide life-saving services for ISAF
and Afghan forces, as well as local civilians.
Humanitarian assistance may be necessary in
accordance with Guidelines on the use of military
assets to support humanitarian Activities in
Complex Emergencies but this is not Governance,
Reconstruction and Development
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Humanitarian Assistance

• The Military are not humanitarian providers
  and should only provide assistance with security
  where this meets Oslo guidelines.
• If engaged in humanitarian activities
  military forces (including medical services) must
  follow the principles of
• Do NO HARM
• Do not contribute to further conflict
• Do not endanger beneficiaries of humanitarian
  assistance

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Humanitarian Assistance

• If there is no civilian alternative, the
  following may be justified
• Provision of emergency first aid
• Evacuation of injured civilians to a local
  medical facility
• Assistance in a natural disaster including
  disease outbreaks such as influenza

Humanitarian assistance   As part of an
operation, the use of available military
resources to assist or complement the efforts of
responsible civil actors in the operational area
or specialized civil humanitarian organizations
in fulfilling their primary responsibility to
alleviate human suffering.
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Medical Rules of Eligibility (MRE)

• Requirement to develop MRE which are operation
  specific and driven by humanitarian assistance
  Principles
• Based on knowledge of Host Nation capability
  capacity
• Cover the provision of assistance where Host
  Nation capability is exceeded in treating
  casualties as a result of conflict/emergency
  (include contingency plans in case all medical
  facilities overwhelmed)
• Consider mechanisms for patients to be
  transferred back to the care of own host nation
  medical system

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Principles humanitarian assistance

• Humanity. The dignity and rights of all those
  sick and injured must be respected and protected
  local cultural requirements must be respected.
• Impartiality. Medical assistance must be
  provided without discriminating as to ethnic
  origin, gender, nationality, political opinions,
  race or religion. Relief of suffering must be
  guided solely by needs, and priority must be
  given to the most urgent cases. Casualties who
  are members of opposing forces must be treated in
  line with this principle medical personnel have
  a responsibility to report violations of this
  principle to an appropriate authority.
• Neutrality. Military medical services are not
  neutral (as they are part of the deployed
  military force) but must treat cases under the
  impartiality principles above
• Independence

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Hearts and Minds

• Short term feel good activities which may
  undermine long term efforts in development and
  dis-empower the host nation government
• Vs
• Long term focused, effects based medical
  engagements which support other development
  efforts and empowers the national healthcare
  system

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MEDCAPS

• Oxfam Report Jan 08 Military projects
  compromise neutrality and scope of humanitarian
  work
• 2nd and 3rd Order effects, including impact on
  civilian safety and overall regional security

MEDCAP (Medical Civil Action Projects)   Deliberat
e direct patient care interventions intended to
deliver medical care to Host Nation civilians,
commonly with an underlying purpose of winning
hearts and minds.
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Second and third order effects

• Security of patients, civilian and military staff
  always needs to be considered including impacting
  on stability
• Disempowering Government efforts
• Creating inequality in access or delivery of
  healthcare
• Competing with host nation healthcare delivery

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Example of difficulties with MEDCAPS

• A MEDCAP was undertaken during a patrol in an
  area of poor security. A woman who attended was
  later mutilated by insurgents, a direct
  consequence of being treated by the foreign
  military. Furthermore, the absence of healthcare
  provision and the poor health of the people in
  this area was not notified to local health
  authorities therefore the need was neither
  highlighted nor taken into consideration when
  planning for healthcare development was carried
  out by the responsible organisations.

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Moving to Medical Outreach

• Based on health needs
• No civilian alternative
• Consent (agreed)
• Planned
• Achievable
• Clinically appropriate
• Resourced
• Risk assessment (risk against benefit)
• Sustainable

Medical Outreach.   Planned, integrated medical
development activity, within the overall health
sector development strategy of the host nation
Government or other responsible body.
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Examples of Medical Outreach (1)

• Local villages in Afghanistan were noted to have
  unsafe water supplies, having had the water
  tested. On discussion with the local population
  through the shura process, and consulting with
  the local director of public health, it was
  decided to invest in a chlorination plant based
  at the local hospital to provide clean water. The
  military sourced the equipment. The Afghan staff
  were taught to operate the machinery and to
  distribute the chlorine. This is now the basis of
  a clean water program for the province.

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Examples of Medical Outreach (2)

• In a rural area in Kandahar province there was
  limited healthcare available, with only two
  comprehensive healthcare centres staffed and many
  locals were not accessing healthcare. It was
  identified that there were concerns over
  travelling times to the healthcare centres with
  the population preferring to access hospitals
  direct if they were ill. On discussion with the
  primary healthcare provider and a representative
  from public health it was identified that some of
  the rural areas did not have the trained
  healthcare workers that is expected from the
  Afghan Basic Package of Health Services. Rather
  than the military giving out medication to each
  village that they happen to pass, which did not
  deal with the underlying health issues, they
  raised funds to pay for the training of
  healthcare workers in those villages without any
  provision. The workers were nominated by the
  local village and were therefore accepted once
  they had completed their training. Medical
  materials in accordance with the BPHS and payment
  to the workers in food/supplies in lieu of a
  salary were also supplied, whilst the issue of
  healthcare workers having to work as volunteers
  when they are on the poverty line was raised at
  the political level in order to work towards a
  long term solution for sustainable healthcare

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Developing Human Capacity

• Focus on building human capacity within the host
  nation health sector, host nation healthcare
  workers providing care
• Providing training, mentoring and partnering may
  need novel methods
• Requires a different type of health professional
  with the ability to teach/mentor/partner in a
  different environment to their own

Diagram amended from an original concept by
Colonel Martin Bricknell
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G,RD principles

• Natsios proposed nine principles for
  reconstruction and development
• 1. Ownership (by the developing nation/fragile
  state)
• 2. Capacity building (of the host nation
  professionals)
• 3. Sustainability (resources for the medium to
  long term)
• 4. Selectivity (targeted)
• 5. Assessment (based on health needs assessment)
• 6. Results (measurable performance of
  interventions)
• 7. Partnership (partnership between agencies
  involved in development)
• 8. Flexibility (plans need to be able to change
  as the situation particularly security changes)
• 9. Accountability (governance)

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Principles providing assistance to health
sector development

• Do no harm. The most important principle in
  providing assistance to health sector
  development. Although almost always well
  intentioned, here is a real risk that the work of
  other agencies might be undermined by the
  involvement of military medical services in
  direct healthcare provision to the host nation,
  and that their security, and that of those
  treated, might be compromised.
• Clinically appropriate. Any intervention must be
  clinically appropriate, taking into consideration
  the capabilities of the healthcare sector and the
  HN governmental institutions policies and
  direction. This might include providing short
  term support as a component of a development
  programme. In sub Saharan Africa for example,
  the provision of cataract surgery returns many
  people to productive lives and thereby improves
  their health development activity would aim to
  support and mentor local ophthalmic surgeons in
  the necessary techniques.
• Culturally sensitive. The provision of any
  health sector intervention must be culturally
  appropriate and socially acceptable to the HN,
  noting the specific issues of gender, and gender
  specific roles in healthcare in many nations.
• Coherent.   The intervention should not be
  focused on just one aspect of RD, such as
  buildings or equipment, as these are often
  unsustainable without attention to other aspects
  of development, for example availability of
  trained staff and mechanisms for meeting
  recurring costs.
• Sustainable. Any intervention should seek to
  ensure that once the military forces withdraw,
  the intervention can be sustained by local
  medical services or NGOs.  Any equipment donated
  must be able to be maintained in the longer term.
• Civilian primacy. Involvement in healthcare
  development must be undertaken only where there
  is no civilian alternative.
• Co-ordination. Medical engagement must only take
  place where there is agreement with the HN
  Government or other appropriate authority
  effective liaison and co-ordination will be
  essential with the Government, NGOs and other
  agencies.

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Development of the host nation military health
sector

• Development of an integral medical capability
  within the host nation in order to provide
  medical support to its own security forces
• Development of the capability to provide
  assistance to the civil community in emergency
  situations, in line with international
  civil-military co-operation principles
• Avoid competition for scarce resources

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Development of medical support to the Afghan
National Army
National Military Hospital Kabul
Combat Medic School Kabul
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Draft Strategy for NATO Medical Engagement in
G,RD

• Purpose
• Scope
• Humanitarian assistance principles
• Governance, Reconstruction and Development
  (G,RD)
• Medical Civil Action Projects (MEDCAPS)
• Medical Outreach
• Coordination
• Strategic Communication
• Outcome measures
• Training
• Lessons learned

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Scope of G,RD Engagement Strategy

• Current NATO operations (ISAF, KFOR)
• All national medical contingents
• Noting different ways of working among national
  contingents

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Strategy development

• Stakeholder analysis
• Military medical stakeholders
• Military commanders
• IOs (ICRC, UN OCHA, WHO, EU)
• Host nation
• Opposing elements (Afghanistan)
• Resources and capabilities
• Environmental analysis

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Guidelines and references

• Natural, Technological, Environmental Disasters
• Oslo Guidelines The Use of Military and Civil
  Defence Assets in Disaster Relief (May 1994 Rev
  1.1 Nov. 2007)
• Complex Emergencies
• MCDA Guidelines The Use of Military and Civil
  Defence Assets to Support United Nations
  Humanitarian Activities in Complex Emergencies
  (March 2003)
• IASC Reference Paper on Civil-Military
  Relationship in Complex Emergencies (June 2004)
• Country / Situation Specific Guidelines

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IMPLEMENTATION

• Endorsement by nations represented at the
  Committee of Chiefs of Medical Services within
  NATO (COMEDS) in Dec 09.
• Introduction of the strategy into NATO current
  and contingent operations by means of an ACO
  Directive in Jan 2010, to complement AD 83-1 ACO
  Directive on Medical Support to Operations,
  together with wide communication of the
  principles and purposes of the strategy.
• Inclusion of these principles within
  pre-deployment training from Jan 2010.
• Evaluation by means of the NATO Operations
  Medical Conference in May 2010, and on an annual
  basis thereafter, and the Lessons Learned
  process, and subsequent incorporation into NATO
  Doctrine following COMEDS plenary Nov 10.
• To be a development of AJMedP 6 Study Draft 5,
  Allied Joint Civil-Military Interface doctrine
  dated Jun 09

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Training

• Individual training
• General professional training
• Role specific training
• Collective training
• With military formation with which to be deployed
• Combined civil-military training
• As part of pre-deployment training
• Long term professional development of health
  leads within G,RD and civil military
  co-operation
• e.g. US Air Force International Health Specialists

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Measurement of effectiveness

• Quantitative measures
• Qualitative measures

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Lessons learned

• The military is not in the lead
• Identify who the stakeholders are
• Engage with host nation and donor governments,
  international organisations, and NGOs, as well as
  military medical and command staff and especially
  colleagues and those in authority within the host
  nation.
• Avoid short termism (problem of short deployments
  and rotation of staff, compounding inappropriate
  selection and suboptimal training)
• Importance of participation

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Presentation by (Danish) orthopaedic surgeon
Role 3
Discussion on amputation technique
Presentation by Chief Surgeon Mir Wais
Presentation by ANA Hospital
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Summary

• Definitions
• Why this issue is important
• What we intend to do about this
• How we will know we have achieved our aim
• Civil-military interface Lessons learned

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QUESTIONS

• Brigadier Robin Cordell
• BSc MB BS MRCGP MFOM DCH DRCOG
• Allied Command Operations Medical Advisor
• Supreme Headquarters Allied Powers Europe
• B7010 SHAPE, Belgium
• robin.cordell_at_shape.nato.int

49
Civil-Military Interface Lessons Learnt
1400 - 1530 Civil-Military Interface Lessons
Learnt Chair and Keynote Speaker Brig Robin
Cordell Co-chair Maj Gen Nunes Marques,
MD Governance, Reconstruction and
Development Brig Robin Cordell Evolvement of
Civil-military Relationship Concept in Nato
Requirements for Medical Cooperation in the Field
of Reconstruction and Development Col Zoltan
Vekerdi, MD Migrants Health New
Challenges Prof Istvan Szilard
50
(No Transcript)
51
Civil-Military Interface Lessons Learnt
1530 - 1600 Coffee 1600 - 1730h Civil-Milit
ary Interface Lessons Learnt Chair and Keynote
Speaker Brig Robin Cordell Co-chair Maj Gen
Nunes Marques, MD CIMIR or CIMIC, Time to End
the Humanitarian Confusion? Knut Ole Sundnes,
MD Title to be announced Col José Donato Ramos,
MD Discussion Panel
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DISCUSSION