The U.S. Department of Defense (DoD) has emphasized that strengthening the will, legitimacy, and capabilities of partner governments and security forces and operating “by, with, and through” them are critical to combating insurgent and terrorist groups around the world. A central element of these efforts is influencing “relevant populations” by supporting the extension of governance, rule of law, and basic services to areas that are undergoverned and vulnerable to exploitation by extremist organizations. Health security is part and parcel of a community's overall well-being, and improving it can help enhance government legitimacy while making extremist groups less attractive to citizens.
The study reported here was undertaken to assist the U.S. Air Force Special Operations Command (AFSOC) in executing its recently developed approach to planning for, assessing, and enhancing the effectiveness of missions for building partner capacity in health (BPC-H). BPC-H is defined herein as systematic, long-term missions to enhance the ability of governments to deliver essential medical, dental, and veterinary services to vulnerable populations in developing states that are important to U.S. interests. The premise of this approach is that helping to improve local public health and the provision of health services supports the extension of good governance and counters insurgent and terrorist infiltration, recruitment, and exploitation. AFSOC believes that its health assets can be more effectively and systematically used by combatant commanders in achieving their theater security cooperation objectives, in conjunction with other organizations, such as the U.S. Agency for International Development (USAID). From a broad U.S. government perspective, BPC-H is intended to be used as a stepping-stone to building strong partnerships with individuals and nations that are important to achieving U.S. national security objectives.
This article documents the results of three research tasks:
- place health security in the context of U.S. strategy and security cooperation efforts
- draw lessons from outside organizations on ways U.S. military forces can maximize their effectiveness in helping build partner health capacity
- offer a framework for planning and executing BPC-H missions based on these lessons.
The Gap Between BPC-H Guidance and Practice
There is ample guidance and direction from DoD on the military's role in building partner health capacity to deliver essential medical, dental, and veterinary services to populations in need. Recent DoD guidance clearly directs the military “to be prepared to perform any tasks assigned to establish, reconstitute, and maintain health sector capacity and capability for the indigenous population when indigenous, foreign, or U.S. civilian professionals cannot do so” (U.S. Department of Defense, 2010, p. 2). Analysis suggests that such services play a critical role in good governance, development, and security.*
However, despite the importance DoD guidance places on health security and on building partner health capacity, few military medical operations are planned and executed to help accomplish this task and sustain local capacity, except in Iraq and Afghanistan. U.S. military organizations regularly conduct medical missions worldwide, but the vast majority of these missions provide direct delivery of health care to indigenous populations. In some operations, such as disaster response and joint training exercises, efforts are understandably constrained by budgets, legal authorities, the focus on the immediate needs of the population, and the operational requirements of the military mission at hand. However, other missions, including medical civic action programs (MEDCAPs) designed to gain and maintain access to strategically important areas, are often misinterpreted as successful capacity building.
Experiences of Other Organizations
RAND reviewed the relevant experiences of a limited number of outside organizations to provide observations and insights applicable to AFSOC's approach to BPC-H. These organizations included the 95th Civil Affairs Brigade (95th CA BDE), AFSOC's 6th Special Operations Squadron (6th SOS), and Project HOPE (Health Opportunities for People Everywhere), a nongovernmental organization (NGO). The 95th CA BDE was selected because it is a Special Operations organization that conducts health activities in austere environments and contributes to DoD's partnership-building efforts through civil-military engagement (CME) missions. The 6th SOS was selected because of its relatively long history in building partner aviation capacity in less-developed nations. Project HOPE has operated in more than 100 countries to strengthen health infrastructure, train medical professionals, and provide humanitarian assistance. RAND also consulted with military health experts in DoD, development experts in NGOs, and other professionals to provide as broad a review as possible. These experts offered a number of insights on identifying strategies, selecting techniques, developing programs, and tracking progress relevant to AFSOC's BPC-H approach; these insights inform the findings and recommendations of this study.
A Framework for Planning and Executing BPC-H Missions
AFSOC's pursuit of BPC-H occurs within a political and institutional context that is defined by national and theater security cooperation priorities and objectives. Appropriate metrics can help inform AFSOC's internal planning, resourcing, coordination, monitoring, and evaluation needs. They can also help communicate progress and achievements to external audiences, such as the Pentagon, other federal agencies, governmental and nongovernmental entities in partner nations, local communities in partner nations that stand to benefit from the provision of better health services, and organizations active in international health and economic development with whom AFSOC and theater commands might associate.
This study proposes a four-phased conceptual approach to planning for, implementing, and assessing the effectiveness of activities to build partner health capacity:
- consult, plan, and prepare for start-up
- launch activities
- conduct full-scale implementation
- draw down, transition, and (possibly) withdraw.
Although theater BPC-H activities would generally involve multiyear efforts in specific health sectors (e.g., maternal health) within individual partner nations, this approach could also be applied to regional efforts. In all four phases, input, process, output, and outcome metrics would help planners monitor alignment of implementation with goals and strategy.
Based on direction from the Theater Special Operations Command (TSOC) for Africa (SOCAFRICA), initial BPC-H efforts focus on the African countries that are included in Operation Enduring Freedom–Trans-Sahara (OEF-TS). The efforts involve instructing these nations' military personnel to enable them to provide initial health services to residents in remote regions and possibly help train civilian providers. The framework is described in terms relevant to this mission, and generic metrics are offered for each of the phases. Specific metrics for particular programs would have to be developed on the basis of the goals and progress of those programs.
Key Findings and Recommendations
The study's key findings are summarized below, and a set of recommendations for maximizing the effectiveness of efforts to build partner health capacity is provided. The recommendations are directed to the U.S. Air Force (USAF) in general and to AFSOC and the theater commands it supports in particular.
- Theater commands are the key to closing the gap between guidance and execution of BPC-H. The requirement for BPC-H is defined in DoD guidance. Theater commands need to direct BPC-H activities—and source them—in order for guidance to be fulfilled. BPC-H missions are relatively inexpensive, but their return can be substantial in terms of both supporting partners and avoiding the cost of later intervention.
- Efforts to build partner health capacity can be either supported or supporting operations. Depending on the operational context, conditions may exist in some regions or states that preclude the U.S. military from training, advising, and assisting existing or potential partners in “kinetic” (combat) capabilities. BPC-H efforts can help “get a foot in the door” and may be a primary means of gaining access and initiating relationships. DoD Instruction 6000.16 recognizes that the priority of such medical operations is comparable to that of combat operations.
- The U.S. Air Force can play an important role in building partner military health capacity. USAF serves as executive agent for the Defense Institute for Medical Operations (DIMO) and provides training in disaster preparedness to foreign countries. Moreover, USAF's International Health Specialists (IHSs), competent not only in medical skills but also in foreign languages and regional knowledge, provide a unique capability for Air Force Major Commands (MAJCOMs) and Geographic Combatant Command (GCC) commanders. Thus, USAF is well-positioned to expand its role in building partner health capacity.
- AFSOC's BPC-H “niche” in the near term appears to be the mission itself. Very few military organizations are systematically pursuing BPC-H as defined here, yet the demand is great. While AFSOC advisors may not need to specialize yet, as the broader Air Force meets guidance by organizing, equipping, and training its medical, dental, and veterinary assets to more systematically conduct BPC-H activities, AFSOC advisors will need to define a more specific niche for their capabilities within the mission.
- Successfully building and sustaining partner health capacity in less-developed regions requires long-term effort and commitment, in synchronization with other military and civilian agencies and organizations, and this may conflict with shorter-term theater command priorities. Without long-term, focused support for the mission from DoD and the theater commands, BPC-H will be sporadic and may not make the impact that it potentially could make. Sporadic missions may even be counterproductive if they raise expectations that the United States cannot meet.
- Given the finding immediately above and the need to involve multiple stakeholders in BPC-H efforts, well-defined, multiyear plans are critical to success. From the outset, plans for enhancing a partner's capacity in a specific health sector must be realistic and based on careful, in-depth assessment of the extant environment in which a BPC-H effort will take place.
Recommendations for AFSOC and USAF
- Communicate the BPC-H concept and approach repeatedly to external audiences. AFSOC health advisors will have to communicate the AFSOC concept to generate greater appreciation among key USAF, DoD, and U.S. government stakeholders of the contribution BPC-H can make to both U.S. and partner interests and to establish a consistent resource stream for the mission.
- In developing plans with theater commands for individual BPC-H programs, schedule multiple visits to the partner nations each year throughout the duration of U.S. military involvement. Visits should be driven not only by the needs of the plan but also by the high-value relationships that can be built with partner nations over time. Sporadic, infrequent visits neither build nor sustain capacity, nor do they enable solid relationships to form.
- Engage stakeholders early in the planning process and in program development and design. Often, partner military capacity in health will be built in the context of efforts by civilian organizations (such as USAID) to work with partner health ministries and civilian medical communities. Moreover, potential associates, such as NGOs, must be included in initial planning, as they need time to prepare for their participation in an activity.
- Assess BPC-H activities by both military and developmental measures of effectiveness. AFSOC and the theater commands will need to show success based on both developmental and military metrics to continue generating support for the BPC-H mission among existing and potential stakeholders.
- Approach early BPC-H excursions with an eye toward learning lessons and adapting procedures based on experience. Engagement in OEF-TS countries offers an opportunity for the theater commands and AFSOC to critically examine the approach to BPC-H.
- Consider the “risk” of success. Given other critical tasks that AFSOC's medical community must perform, including force health protection and casualty care, AFSOC will need to understand and evaluate the trade-offs it is making between BPC-H and other requirements if demand for BPC-H missions rises.
- Examine whether and how AFSOC's BPC-H concept and approach are scalable to the general-purpose Air Force. If USAF decides to embrace the mission in a systematic fashion, it will be necessary to examine AFSOC's approach and to understand how it can be applied on a larger scale.
- Consider dedicating some USAF and/or other MAJCOM-level resources to forming a cadre of medical personnel with regional focus and expertise in BPC-H planning and execution. USAF might determine whether a cadre of medical personnel dedicated to BPC-H (potentially including an expanded IHS program) is warranted.
The research described in this article was sponsored by the United States Air Force and conducted by RAND Project AIR FORCE.
Jones, Seth G., Lee H. Hilborne, C. Ross Anthony, Lois M. Davis, Federico Girosi, Cheryl Benard, Rachel M. Swanger, Anita Datar Garten and Anga R. Timilsina, Securing Health: Lessons from Nation-Building Missions, Santa Monica, Calif.: RAND Corporation, MG-321-RC, 2006. As of March 8, 2012: http://www.rand.org/pubs/monographs/MG321.html
U.S. Department of Defense, “Military Health Support for Stability Operations,” DoD Instruction 6000.16, May 17, 2010.
* See, for example, Jones et al., 2006, p. xxi.