CONCEPTUAL APPROACHES TO DEVELOPING MILITARY MEDICAL DOCTRINE

CONCEPTUAL APPROACHES TO DEVELOPING MILITARY MEDICAL DOCTRINE

O. Shekera,

MD, Dr. Sc., Full Professor, Retired Colonel, Ukrainian Army Medical Service

Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine

Abstract. The paper focuses on the main conceptual points of the Military Medical Doctrine of Ukraine. There are discussed the approaches to reforming the Ukraine Armed Forces medical support system, which key tasks are to upgrade the military medical structure.

Key words: Military Medical Doctrine, medical support system, military medicine.

Introduction. The current approaches to the funding of the military medical care, arrangement of administering medical aid, the state of the armed forces and military medical services are given the highest global governmental priorities.

Reforming the military medical services of the armed forces in each country depends on a wide range of different factors, including macroeconomic conditions, social and political environment and social values, the combined economic, social, demographic, administrative, technological and ideological conditions. The current structure of the armed forces has a direct influence on the reform process.

For example, the Doctrine for the Armed Forces of the United States is part of the concept of the military medical readiness, it is declared as "Fundamental principles by which the military forces or elements thereof guide their actions in support of medical objections", and contains fundamentals necessary to achieve the major objectives of medical service which is to provide the medical readiness of troops for successful performing the peace-support, police, humanitarian missions and military operations, executing mainly outside the United States (including the areas with adverse climatic, sanitary and epidemiological conditions, hostility of the residential population group). The US military medicine is regarded as a specific branch to prevent and treat the diseases and injuries related to military service and combat features. In peacetime its main objective is to support the adequate standard of health and combat readiness by implementing health promotion programs, hygienization and epidemiology, bodily exercises, protection against occupational hazards, timely medical care. In time of war the main task is to keep as many wounded people as possible alive, to reduce disability and bring them back safe.

Today ensure the national security of Ukraine is a strategic task and essential function of every independent state, the main activity of its political and governmental institutions. The national security of Ukraine aims to the full implementation of the vital interests of a man, society and the state, enabling environment for the existence and development of the nation, preservation and enhancement of its material and spiritual values.

Performing the mentioned functions of the state in the course of the armed conflicts needs the coordinated efforts and capabilities of the Medical Service corps of Ukraine and the other security structures of the state, as well as complete requisitioned institutions, civil health institutions and medical organizations of the other ownership within an integrated medical space on the basis of the Military Medical Doctrine of Ukraine.

Objective. To cover the conceptual approaches to creating the Military Medical Doctrine of Ukraine and consider its major component, namely "The fundamentals of health military maintenance organization".

Research materials and methods. There were used the methods of semantic evaluation of scientific documents, statistics, structural and logical analysis.

Results and discussion. The Military Medical Doctrine of Ukraine is one of the major strategic health planning documents in the state and is a combination of scientifically based principles that define the system and methods of medical support of the combat forces in the specific circumstances, including the means and methods of warfare, the level of medical science and practice, the state of capabilities and the features of combat theater.

The legal platform of the Military Medical Doctrine of Ukraine is the Constitution of Ukraine, Laws of Ukraine, Military Doctrine of Ukraine and other normative legal documents on healthcare, the state defense and the Armed Forces of Ukraine.

The Military Medical Doctrine of Ukraine is of the exclusively peaceful nature and is based on the Geneva Convention Relative to the Treatment of Prisoners of War. The fundamentals of the Military Medical Doctrine apply to the health care, medical support of the Armed Forces of Ukraine and the other security structures of the state; they are basic for developing the other legal acts and guidelines.

The Military Medical Doctrine of Ukraine defines the responsibilities of government bodies for the development of the medical service of the Armed Forces of Ukraine and civilian health care institutions and their capacity for health protection of individuals, society and the state in case of internal and external military threats, involving the use of force or threat of force and the ability to resist. The number of military and civilian health care institutions, involved for army medical support in wartime, is determined by the Government of Ukraine in accordance with the Laws of Ukraine.

The Military Medical Doctrine of Ukraine includes the following sections: general provisions; foundations of the arrangement of medical support of the armed forces; emergency medicine public service; principles regarding population protection; manning and equipping; general questions relevant to the activities of medical and pharmaceutical professionals (figure 1).

The purpose of the Military Medical Doctrine of Ukraine is to prevent and minimize casualties, the protect and preserve the life and health of the population, including the military, in the face of attacks, that is achieved by creating a unified system of medical support of the military and the population on the basis of an adequate level of the arrangement, the presence of modern technical equipment, comprehensive resources.

One of the major components of the Military Medical Doctrine of Ukraine "The Fundamentals of Health Military Maintenance Organization" is considered more particularly. The basic items of formational strategies of the system of health military maintenance in peacetime and wartime are determined by the state policy and especially by the Ministry of Defence of Ukraine and Ministry of Health of Ukraine, which is formed as a result of in-depth study and analysis of this issue at the present time in Ukraine. More details of these issues are presented below.

1. Principles of medical support to the armed forces. Тhe Military Medical Doctrine of Ukraine is based on the following basic principles: 

recognizing life and health of every citizen (servicemen) of Ukraine as the highest value;

recognizing the Armed Forces Medical Services and other state security sector institutions activity as one of the priorities of the society and the government;

upholding the rights and freedoms of  man and citizens (servicemen) in the field of healthcare, and keeping the related government guarantees;

guaranteeing the equality of citizens (servicemen), democracy and accessibility of health care;

developing and implementing state policy in the field of military and civilian medical education;

developing and implementing  state policy in the field of military medicine and civilian health care;

taking preventive and integrated approach to social, environmental and medical problems in health care;

focusing  on current standards of health and medical care, a combination of local traditions and international achievements in the field of military medicine and civilian health care;

taking systematic approach to the organization of the medical service of the Armed Forces and civilian health care while strategic planning;

unified approaches to organizational principles of the medical service of the Armed Forces Medical Services and other state security sector institutions, civilian health care institutions, regardless of subordination and complete use of the potential of macro conditions concerning  efficient medical support in wartime;

forming an accessible, versatile and effective system of medical support to the Armed Forces, which provides medical care on an area basis through united efforts and coordination of military medical services involving mobilization and civilian healthcare institutions and medical organizations of all forms of ownership;

providing efficient medical and evacuation, sanitation and anti-epidemic measures, all elements of medical support on the basis of proper organization, the modern technical equipment, comprehensive resources supply;

ensuring mixed economy of military medicine and civilian health care and their multi-source funding combined with state guarantees; 

ensuring high mobilization and combat readiness of the Armed Forces Medical Services and other state security sector institutions which means providing efficient transfer of peace in martial law and ensure the proper level of readiness for their use;

scientific, logistical, financial and economic substantiation of the activity of the Armed Forces Medical Services and other state security sector institutions, civilian health care institutions.

The system of the medical support to the Armed Forces of Ukraine and other state security sector institutions, mobilization and civilian healthcare institutions and medical organizations of other forms of ownership within a unified medical space is based on: strict hierarchy and centralization; clear separation of functions; effective cooperation.

2. Organizational principles and effectiveness of the medical service of the Armed Forces and other structures of the security sector of the state and civil health care, building patterns and functions of medical support of the troops are determined by the Military Doctrine of Ukraine, the principles and provisions of the military and medical science.

Functioning of the system of medical support is based on:

preserving the required level of the population’s health as a determinant of readiness and combat capability of military forces of the State;

unified organizational requirements to methods of prevention, diagnosis and treatment of the sick and wounded (national medical standards, clinical protocols and military medical standards);

timeliness, continuity and sequence of medical care and treatment of the sick and wounded;

divarication of a unified medical-evacuation process into a number of successive interrelated activities that meet certain levels of care combined with the evacuation of the wounded and sick as intended;

echeloning and approaching of medical care, including specialized care to the wounded (sick) through the use of modern medical technology and reducing the number of of medical care stages;

the principle of territoriality in a single medical space of the country;

relative autonomy, high mobility of the forces and facilities of medical service of the Armed Forces and other structures of the security sector of the state and civil health care;

high combat and mobilization readiness (forming the required reserve), maneurability and rational use of the forces and facilities of medical service of the Armed Forces, other structures of the security sector of the state and civil health care;

maintaining constant readiness of the forces and facilities of medical service of the Armed Forces and other structures of the security sector of the state and civil health care concerning medical support of the troops;

optimization of national and sectoral medical and social measures (physical, psychosomatic and social rehabilitation to prevent disability and incapacitation, return to the Armed Forces or employment);

optimization of direct and indirect financial costs by reducing soldiers’ morbidity and mortality;

ensuring the constitutional rights of all categories of the population, including soldiers and their families.

3. The organizational structure of the medical service of the Armed Forces of Ukraine depends on the organizational structure, objectives and nature of the hostilities and kind of the Armed Forces, the characteristics of health care as well as on the tasks assigned to its appropriate formations. The general management of the medical service is performed by the Armed Forces of Ukraine through subordinate military medical leaders.

Medical Service of the Armed Forces of Ukraine is to fulfil the tasks as follows:

medical support of combat training of the troops (forces);

high level of combat and mobilization readiness of forces and facilities of medical service;

participation in the Armed Forces healthy replenishment;

organization and implementation of measures for the preservation and enhancement of personnel’s health;

sanitary and epidemiological support of the troops (forces);

delivery of health care and treatment of the military;

organization of combat training and advanced training of the medical service personnel;

provision of the troops (forces) with medical property;

military medical training, promotion of hygiene knowledge, healthy lifestyle;

scientific support for the system of medical support of the troops.

4. Organization of medical and evacuation support. Medical care is delivered to the wounded (sick) at medical subdivisions of military units and formations, military and civil health care facilities which form the basis of the stages of medical evacuation. A number of medical evacuation stages, place of the deployment as well as types and quantity of medical care delivered are to be determined by the operational and combat conditions and size of losses.

The basic principles of medical evacuation deployment stages involve the maximum approaching to foci of health losses, echeloning and reducing the number during treatment and evacuation process.

The organization of medical diagnostic work involves a solution to the problems as follows:

optimization of the capacity and structure of  hospitals to meet the needs, given the characteristics of the region;

improving the efficiency of specialized medical care through the introduction of modern technologies, quantity and quality of medical care standards compliance;

distribution of interregional diagnostic and rehabilitation facilities (centers) network;

providing leadership of research institutions in development and implementation of advances in medical science, technology, innovative technology for the benefit of the Armed Forces.

Medical service of the Armed Forces of Ukraine and civil health care operate in a single medical space through the unified  state legislation regarding health care, compliance with national health standards, clinical protocols and military medical standards of care delivery.

5. Preventive principles of medical support system of the troops. Prevention contents of medical support system is seen as a complex of state measures to create healthy lifestyle and provide a favorable environment, the introduction of preventive technologies in health care settings and sanitary-epidemiological activity.

The state promotes the military and  general population’s healthy lifestyle through spreading scientific knowledge about health care, the organization of health, environmental and physical education, the implementation of measures aimed at improving hygienic culture of the  military and general population, creating the necessary conditions, including medical monitoring, physical training, sport and tourism, development of medical and athletic facilities network, dispensaries, recreation centers and other health facilities to combat harmful habits, establishing a system of social and economic incentives for people who lead healthy lifestyle.

In order to protect the military and  general population’s health, military and medical service and health care authorities and  institutions  are required to implement special measures for prevention and treatment of socially dangerous diseases (tuberculosis, mental health, sexually transmitted diseases, AIDS, leprosy, chronic alcoholism, drug addiction) and quarantine diseases.

Procedure for admission and treatment of patients, including those in the enforcement procedure is established by legislative acts of Ukraine.

Commanders at all levels are responsible for the implementation of measures to prevent disease and injuries in subordinate to the Armed Forces units and other structures of the security sector of the state.

6. Drug, procurement and logistic support. The condition and development of drug, procurement and logistic base of the medical support system depends on military-technical policy, economic opportunities of the state and developing national science in all areas and is to be provided through:

military medical orientation of  science, technology and innovation policy for the development of new medical technologies and new drugs, medical and technical means of dual use;

scientific, technical, information and resource independence, which involves the development and useof  medical devices, equipment and property of domestic production in wartime.

Production of new drugs and immunobiological preparations of dual use for medical purposes is allowed with the permission of the central executive body that implements the state policy in the field of health after establishing therapeutic or prophylactic efficacy.

The quality of medicines and immunobiological preparations of dual use is to meet the requirements of the  State Pharmacopoeia of Ukraine and specifications approved according to the established procedure.

The quality control of medicines and immunobiological preparations of dual use manufactured in Ukraine is to be carried out by the central executive body that implements the state policy in the field of quality control and safety of medicines.

Policy of drug, procurement and logistic base development of the medical support system is to be based on the following activities:

availability, quality, safety of medical software as an important component of the military’social protection programs;

introduction of state protectionism policy for medicines and medical equipment of domestic production (their compliance with European standards of quality and proven bioequivalence);

improving the system of control, standardization and certification of medical and pharmaceutical industries.

The system of standards in health care comprises state norms and industry standards.

State social standards in health care are governed in accordance with the current legislation of Ukraine.

7. Socio-economic and legal components. Social protection of the military involves meeting the requirements of  the Ukrainian legislation and the development of state legislation pertaining  medical support of the military.

Government policy is aimed at maintaining and improving the military’s health and involves:

creation of appropriate living, working, rest and recovery conditions, appropriate level of financial security for the military;

implementation of state measures for environmental sanitation, environmental welfare;

responsibility of the State for the efficient operation of medical support, the preventive orientation;

restructuring the system of medical support of the troops;

meet the needs of the military in a guaranteed level of care;

funding of medical support at levels appropriate to the scientifically justified needs and adequate compensation of military and civil healthcare workers;

compulsory life insurance, health and social insurance of military and civil healthcare workers;

protection of professional, property, personal rights and other rights of medical professionals.

8. Computerization of medical service. Computerization defines the main directions of development and principles of information-analytical systems in military and medical service and includes the development and implementation in practice  new forecasting and analytical systems,  automation of technological processes of medical diagnostic and other types of military and medical services, automation of control, etc.

Computerization ensures the creation of appropriate information systems, including the management of medical service at all levels, creating the registry of the medical data of the military of the Armed Forces and other structures of the  security sector of the state (except for the Security Service of Ukraine, the Foreign Intelligence Service of Ukraine) as well as providing military entry of  medical information system to the state field computer network.

To identify the wounded, casuaties and killed and create a unified system of medical logistics (evacuation, treatment and rehabilitation) there is  applied a unified implanted electronic identifier of the individual.

9. International cooperation and humanitarian law. Ukraine participates in international  health cooperation, is a member of the World Health Organization (WHO) and other international organizations. The State guarantees the specified organizations the relevant  conditions of activity in Ukraine, promotes the expansion and deepening of Ukraine's participation in the held events.

Participation of medical services of the Armed Forces of Ukraine and other security sector structures of the state in medical support of coalition and multinational forces.

General principles and requirements to the medical support of the troops are to be developed and implemented on the basis of the legislation of Ukraine in Health, national medical standards and clinical protocols of care delivery given the requirements of the United Nations, WHO, Geneva Conventions On the Protection of Victims of War.

Unlawful restriction of international cooperation by the public authorities and officials may be appealed to the established order, including the court.

10. Сoordination and management of medical support. For the period of local armed conflicts (counterterrorism) or during emergencies under the National Security and Defense Council of Ukraine there is established the Center of  Interagency Coordination of  Civilian and Military Health Care (hereinafter - the Center).

The Center provides operational management, interagency coordination and control in the system of medical support of the Armed Forces of Ukraine, other structures of the security sector of the state and participating institutions, civilian health facilities and medical organizations of  other ownership within a single medical space.

The authorithies and functions of the Center are developed and approved by the National Security and Defense Council of Ukraine.

The consolidated guidance of  medical support of the Armed Forces of Ukraine and other structures of the security sector of the state and participating institutions, civil health facilities and medical organizations of other ownership within a single medical space in wartime is conducted by medical leadership of the Armed Forces of Ukraine.

11. The Authority and Responsibility for Management of Medical Support. The government develops the legal and regulatory framework of the medical services of the Armed Forces of Ukraine, other national security and civil health care system organizations, ensures its implementation and provides finance and resources provision in accordance with the needs of medical support for the forces and civilians in wartime.

The medical services of the Armed Forces of Ukraine, other national security and civil health care system organizations develop joint regulations and policies concerning the implementation of the provisions of this Doctrine, apart form the required set of capabilities and means of medical services of the Armed Forces, other national security and civil health care system organizations, train state order for the required number of medical and logistical resources, create and keep in constant readiness certain number of the forces and means of medical service.

The Ministry of Health of Ukraine together with the Ministry of Defence of Ukraine creates and maintains a certain amount of local hospital bases according to their powers for medical support for the forces and civilians in wartime.

12. Finance and Resources Provision. The State Budget of Ukraine and local budgets allocated to the health care are used to provide a guaranteed level of public health care, funding for the state target and local health care programmes and fundamental research studies on these issues.

The finance and resources provision for the medical service of the Armed Forces and other national security organizations is guaranteed and realized on the basis of target budget financing with economically sound its combination with the insurance and other forms of financing. The medical services of the Armed Forces and other national security organizations provide achieving an optimal level of medical, social and economic efficiency.

The medical service of the Armed Forces and other national security organizations is supplied with medical and technical equipment mostly of dual-use, module-based and also with modern sanitary equipment, which ensure their autonomy and mobility. The fitting out (retrofitting) of the medical services of the Armed Forces and other national security organizations is performed by the software-based method.

The state provides orientation of the production sector of the country to meet the individual needs of the medical services of the Armed Forces and other national security organizations with regard to design engineering and production of national land, water and air transport, which easily adapts to the needs of patient evacuation.

The state forms reasonable volumes of immobile and mobilization reserves to provide the activity of the medical services of the Armed Forces and other national security organizations, сivilian health.

The state provides the servicemen with reasonable guaranteed hospital volume and participates in their compulsory medical insurance.

To maintain and improve conditions, increase the quality of medical care delivery for servicemen there was made provision for additional extrabudgetary funding sources, including introduction of medical insurance of persons serving and working in the Armed Forces of Ukraine and other national security organizations.

Health care facilities and medical entities of the Armed Forces of Ukraine and other structures of the security sector of the state, civil health system which produce goods required to support activities of health care facilities pertaining to medical provision of the military and civilian population in wartime, are to enjoy tax and other benefits provided by the law.

The military, certain categories of employees of the Armed Forces of Ukraine and other security sector structures of the state as well as volunteers are subjects to mandatory health insurance.

Mandatory health insurance is based on the principles of:

equal opportunity of health care access regardless of health status or income of the insured persons at the expense of insurance contributions;

free of charge health care;

equal conditions  in the market of mandatory health insurance for health care providers regardless of ownership;

state-guaranteed funding for mandatory health insurance;

targeted use of mandatory health insurance;

support of medical care to insured persons under the industry standards in military health care;

parity of state representatives, insurers and insured persons in the management of mandatory  health insurance;

unavoidability of punishment for insurers, insurance companies and health care providers in case of violations committed in mandatory health insurance.

Mandatory health insurance of the military is provided by the Military Insurance Company and / or insurance companies which are the members of the health-insurance pool and/ or insurance companies which obtained the relevant accreditation.

None of the provisions in this doctrine may be interpreted as being aimed at reduction in the State’ responsibilities to ensure adequate funding of medical support of the military, in particular to reduce or eliminate current programs in this area.

13. Scientific Support. Scientific support of the medical service of the Armed Forces of Ukraine and other national security organizations is carried out by the National Academy of Medical Sciences of Ukraine together with the Ministry of Defence of Ukraine, Ministry of Health of Ukraine, Ministry of Education and Science of Ukraine and other relevant ministries and agencies which:

organize and direct activities of the research institutions and establishments of Ukraine on solving the problems of military medicine;

ensure the development and implementation of modern medical technologies of medical care, treatment and rehabilitation of servicemen and civilians in the event of injuries, traumas and diseases, both in the field and at the hospital;

carry out scientific support of the development of national medical equipment, property and dual-use technical equipment, medical and maintenance products for the Armed Forces of Ukraine and other national security organizations.

Formulation and implementation of the state target programmes of civil and military medicine using their scientific and technological potential by encouraging fundamental, applied and exploratory research for the medical support of the Armed Forces of Ukraine and other national security organizations, сivilian health.

Conclusions

All in all, the main goal of the modern system of medical support of Ukraine and other structures of the  security sector  of the state, civil health  care is to prevent, restrict and minimize the extent of the military’s and civilians’ loss in peacetime and wartime by creating guaranteed opportunities for  the organized response of military medical services. The range of the goal includes: securing high quality medical care and evacuation, sanitary and anti-epidemic measures, all elements of medical support on the basis of adequate levels of the organization; modern technical equipment and extensive resource support.

The Military medical doctrine must be the basis for the formation of normative legal framework of medical services of the Armed Forces of Ukraine and other structures of the security sector of the state, civil health care in peace and wartime.

Implementation of the Military Medical Doctrine is ensured by the Cabinet of Ministers of Ukraine and state agencies under the authority defined by the Constitution and laws of Ukraine.

References

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Author: Oleh Shekera,

Director of the Family Medicine Institute, Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine

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