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Framework for analysing and fostering civilian–military medical relations

We applaud Leone et al for the concise presentation of the salient considerations necessary for the evaluation of a military health system. This is a highly valuable endeavour, particularly enhanced by the authors providing clear distinctions between military and civilian sectors. The applicability of this framework could be widened with further development of Section 6: Civil–military relations. We believe the following areas discussed are pertinent to assessing civilian–military relations. The current COVID19 pandemic has exposed the vulnerabilities of healthcare systems around the world, both in established and emerging economies alike. With the unprecedented strain on national healthcare systems, several countries have sought military medical services assistance to augment detection, quarantine, and treatment of patients with COVID19 in the early stages of the pandemic, and currently vaccination programmes in this later stage. This observation prompted researchers to investigate the role of civilian–military medical collaborations in future healthcare challenges that demonstrate rapidly evolving health emergencies. When undertaking such an endeavour, it is vital to understand (1) the context from which these collaborations sprout, (2) the driving forces, (3) the component(s) of the military health system best suit for merging, and (4) how to operationalise challenges and mitigation strategies. There are documented focal examples of civilian–military collaborations in disaster responses, refugee crisis and training. The maintenance of a military medical force that has experience with warrelated trauma is a challenge in times of peace. This ‘Walker’s dip’ has prompted US military leaders to seek civilian trauma medical institutions as favourable training options to maintain this experience (clinical readiness). 4 While many broad strokes have been accomplished in the arena of civilian– military relationships, we need to accrue granular data from multiple countries with varied contextual parameters and define challenges to strategise remedial action and foster effective collaborative effort. Towards these, researchers need to standardise terminology and tools used in analysing military and civilian healthcare system collaborations. Table 1 includes suggested terminology based on the varied breadth of civilian–military relationships. In the current medical literature, the terms partnership, relationship, engagement, interaction, exchange, collaboration and integration are used interchangeably to describe military and civilian medical joint ventures without explicitly defining its policy, governance, legislative and operational metrics. Further, there is a need for scalable integration metrics to identify, compare differences in each country and understand the dynamics between preconflict, conflict, postconflict and peace. We advocate for inclusive expert consensus in defining terms, identifying parameters and constructing metrics to facilitate civilian– military collaboration research endeavours.