civil-military interface lessons learnt chair and keynote speaker: brig robin cordell co-chair: maj...
TRANSCRIPT
Civil-Military Interface Lessons Learnt
Chair and Keynote Speaker: Brig Robin CordellCo-chair: Maj Gen Nunes Marques, MD
Civil-Military Interface Lessons Learnt
14:00 - 15:30
Civil-Military Interface Lessons Learnt
Chair and Keynote Speaker: Brig Robin CordellCo-chair: Maj Gen Nunes Marques, MD
Governance, Reconstruction and DevelopmentBrig 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 ChallengesProf Istvan Szilard
Civil-Military Interface Lessons Learnt
15:30 - 16:00
Coffee
16:00 - 17:30h
Civil-Military Interface Lessons Learnt
Chair and Keynote Speaker: Brig Robin CordellCo-chair: Maj Gen Nunes Marques, MD
CIMIR or CIMIC, Time to End the Humanitarian Confusion? Knut Ole Sundnes, MD
Title: to be announcedCol José Donato Ramos, MD
Discussion Panel
Governance, Reconstruction and Development (G,R&D)
Brigadier Robin CordellBSc MB BS MRCGP MFOM DCH DRCOG
Allied Command Operations Medical AdvisorSupreme Headquarters Allied Powers Europe
B7010 SHAPE, [email protected]
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
ALLIED COMMAND OPERATIONS (ACO)
ACO(SHAPE)
JFC BRUNSSUMJC LISBON
(Maritime Ops)JFC NAPLES
MCC NAPLESLCC MADRIDACC IZMIR
KFORNTM-I
MCC NORTHWOODLCC HEIDELBERG
ACC RAMSTEINISAF
Military Committee
Allied Command Transformation
NATO HQ (Brussels)
COMEDS
CO-OPERATION AS THE IMPERATIVE
MEDICAL SUPPORT TO MARITIME OPERATIONS
• Maritime operations• Littoral operations
Definitions and context
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
G,R&D Operational Planning Model
SHAPE CLEAR BUILDHOLD
Humanitarian AidHUMINT
Needs of the District
Tipping Point for Population Support
Pervasive ANSF-Led ISAF Enabled Information Operations Campaign
HTTsPatrols
Defin
eDe
fine
DeliverDeliver
InformInform
Cultural Affairs
Religious Affairs
Loca
l Eco
nom
yLo
cal E
cono
my
Health
EducationGovernance
R&D
CoalitionCoalition ANA Lead ANA Lead
ANA LeadANA Lead
PRT Lead PRT Lead
ANPANP ANPANP
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.
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.
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.
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.
Development
• Intervention to support improvement in the provision of essential services in a community or a nation, through building sustainable capacity.
ANDS (MDGS) HNSS Implementing SOPs
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
Essential Package of Hospital Services
Basic Package of Health Services
(NH)NAT’LHOSP
(RgH)REGION
HOSPITAL
PROVINCIAL HOSPITAL (PH)
DISTRICT HOSPITAL (DH) 100K – 300K
Surgery, x-rays, OB. Has female OB/GYN, surgeon, pediatrician, lab, pharm, dental.
*COMPREHENSIVE HEALTH CENTER PLUS (CHC+)70K – 90K
More robust inpatient care (10 Beds) and ancillary services than a CHC.Provides services to a larger population where a DH is not available.
COMPREHENSIVE HEALTH CENTER (CHC)30K – 60K
Limited inpatient care, lab. Severe childhood illness, malaria.Staffed with male / female doctors, nurses, midwives, lab, pharmacy techs.
BASIC HEALTH CENTER (BHC)15K – 30K
More complex outpatient care than HP. OB; routine immunizations; childhood diseases; treatment of malaria, TB; and care for mental health patients and disabled.*SUB-CENTER
3K - 7KBasic health services delivered by one male nurse and one community midwife from private homes.
Offers the same services as a Health Post and established to provide intermediate care between the BHC and HP.
HEALTH POST (HP)Covers 1000 – 1500 Afghans Basic health services delivered by community health workers (CHW) from their own homes.
Afghan Health Service
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
Humanitarian assistance, development and security sector reform
Humanitarian assistance
(emergencies)
Humanitarian assistance
(emergencies)
Development of the military
healthcare system
Development of the military
healthcare system
Development of the civil healthcare
system
Development of the civil healthcare
system
ISAF medics saving lives in Sangin
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.
24 Mar. 2009PR# 2009-280
Humanitarian assistance may be necessary in accordance withGuidelines on the use of military assets to support humanitarian Activities in Complex Emergencies – but this is not Governance, Reconstruction and Development
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
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.
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
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
“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
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) Deliberate direct patient care interventions intended to deliver medical care to Host Nation civilians, commonly with an underlying purpose of winning “hearts and minds”.
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
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.
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.
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.
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
• 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
Host nation patients
Host nation Interpreters
Westernstaff
Replacing host nation healthcare
Host nation patients
Host nation Professionals
Western/other NATOstaffImproving host n
ation healthcare
Developing Human Capacity
Diagram amended from an original concept by Colonel Martin Bricknell
G,R&D principlesNatsios 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)
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 R&D, 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.
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
Development of medical support to the Afghan National Army
National Military HospitalKabul
Combat Medic SchoolKabul
Draft Strategy for NATO Medical Engagement in G,R&D
• Purpose• Scope• Humanitarian assistance principles• Governance, Reconstruction and Development (G,R&D)• Medical Civil Action Projects (MEDCAPS)• Medical Outreach• Coordination• Strategic Communication• Outcome measures• Training• Lessons learned
Scope of G,R&D Engagement Strategy
• Current NATO operations (ISAF, KFOR)• All national medical contingents• Noting different ways of working among
national contingents
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
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
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
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,R&D and civil military co-operation– e.g. US Air Force International Health Specialists
Measurement of effectiveness
• Quantitative measures• Qualitative measures
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
Presentation by (Danish) orthopaedic surgeon Role 3 Discussion on amputation technique
Presentation by Chief Surgeon Mir WaisPresentation by ANA Hospital
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
QUESTIONS
Brigadier Robin CordellBSc MB BS MRCGP MFOM DCH DRCOG
Allied Command Operations Medical AdvisorSupreme Headquarters Allied Powers Europe
B7010 SHAPE, [email protected]
Civil-Military Interface Lessons Learnt
14:00 - 15:30
Civil-Military Interface Lessons Learnt
Chair and Keynote Speaker: Brig Robin CordellCo-chair: Maj Gen Nunes Marques, MD
Governance, Reconstruction and DevelopmentBrig 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 ChallengesProf Istvan Szilard
Civil-Military Interface Lessons Learnt
15:30 - 16:00
Coffee
16:00 - 17:30h
Civil-Military Interface Lessons Learnt
Chair and Keynote Speaker: Brig Robin CordellCo-chair: Maj Gen Nunes Marques, MD
CIMIR or CIMIC, Time to End the Humanitarian Confusion? Knut Ole Sundnes, MD
Title: to be announcedCol José Donato Ramos, MD
Discussion Panel
DISCUSSION