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A Systems Perspective of DoD Global Health Engagement.

INTRODUCTION
A systems perspective was used to describe U.S. Department of Defense (DoD) Global Health Engagement (GHE). This description was based on DoD instructions and higher-level documents related to DoD GHE. A complex system of systems such as health care can benefit from using modeling approaches to help understand the interactions among major components. Models (conceptual, computer-based programs, realistic simulations, or training exercises) can be used to help stakeholders prioritize options and to identify important components and gaps for making performance improvements. Based on the cited documents, we identified major DoD GHE components to create a conceptual model.


MATERIALS AND METHODS
Components were selected from DoDI 2000.30 for DoD GHE. Definitions of these interacting components are given and assigned to our network model that consists of three levels: strategic, operational, and tactical. These levels are linked by critical nodes (decision points) that allow feedback to previous levels for modifying appropriate components. A network that is reminiscent of this structure is Boyd's observe-orient-decision-act diagram. Acceptable strategic and operational plans are linked to the tactical level. Acceptable tactical components lead to the desired outcome of accomplishing the DoD GHE goals. Complex systems also have feedback loops to allow for component evaluations and modifications. Accomplishing DoD GHE goals need to have adaptable components in dynamic permissive environments.


RESULTS
The network that we considered is multicomponent and interdisciplinary. The network uses DoD GHE goals as the input (observing in the observe-orient-decide-act loop) to provide relevant information. It consists of three levels of adaptable, interacting (orienting) components that are linked by critical nodes (decision points) involving the evaluation of plans and desired outcomes. Strategic components (eg, sharing, personal interactions, agreements, planning, readiness, etc.) are required to develop strategic plans, the first critical node. If these plans are acceptable, the information is passed on (feed forward, action) to the operational components (define problems, understand strategic direction and guidance, understand the operational environment, etc.). At the second critical node, the decision is made about moving the operational plans to the tactical components (eg, evaluation, data, training, etc.). Tactical components are essential to provide further information to the third critical node, desired outcomes, in accomplishing DoD GHE goals. Feedback from all critical nodes is essential to allow modifications of various components and to attain health-related interoperability in supporting security policies and military strategies.


CONCLUSIONS
Examining the composition of DoD GHE and creating a defined model can help identify interacting features of this complex system. All of the identified components have been associated with gaps, such as the need for monitoring and measuring tools, and standards. The current state of this system is dynamic and is evolving when confronting gaps. DoD GHE represents an intersection of global health and security in supporting U.S. national security objectives by establishing access and influence with partner nations and among health care-related government and non-government organizations, and as a result, improves the readiness, health, and safety of our military personnel.