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Civil-Military Interface Lessons Learnt

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Title: Civil-Military Interface Lessons Learnt


1
Civil-Military Interface Lessons Learnt
  • Chair and Keynote Speaker Brig Robin Cordell
  • Co-chair Maj Gen Nunes Marques, MD

2
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
3
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
4
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

5
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

6
ALLIED COMMAND OPERATIONS (ACO)
NATO HQ (Brussels)
Military Committee
COMEDS
Allied Command Transformation
CO-OPERATION AS THE IMPERATIVE
7
Medical Support in the Joint Operational
Environment
8
MEDICAL SUPPORT TO MARITIME OPERATIONS
  • Maritime operations
  • Littoral operations

9
Definitions and context
10
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

11
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
12
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.

13
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.

14
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.

15
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.

16
Development
  • Intervention to support improvement in the
    provision of essential services in a community or
    a nation, through building sustainable capacity.

17
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
18
Afghan Health Service
Essential Package of Hospital Services
Basic Package of Health Services
19
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

20
Humanitarian assistance, development and security
sector reform
Humanitarian assistance (emergencies)
Development of the civil healthcare system
Development of the military healthcare system
21
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
22
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

23
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.
24
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

25
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

26
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

27
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.
28
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

29
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.

30
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.
31
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.

32
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

33
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
34
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)

35
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.

36
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

37
Development of medical support to the Afghan
National Army
National Military Hospital Kabul
Combat Medic School Kabul
38
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

39
Scope of G,RD Engagement Strategy
  • Current NATO operations (ISAF, KFOR)
  • All national medical contingents
  • Noting different ways of working among national
    contingents

40
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

41
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

42
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

43
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

44
Measurement of effectiveness
  • Quantitative measures
  • Qualitative measures

45
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

46
Presentation by (Danish) orthopaedic surgeon
Role 3
Discussion on amputation technique
Presentation by Chief Surgeon Mir Wais
Presentation by ANA Hospital
47
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

48
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
52
DISCUSSION
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