Rendering Mercy in Timor-Leste: the Role of U.S. Navy Hospital Ships in Strengthening Partnerships by Derek Joseph Licina M.P.H

Rendering Mercy in Timor-Leste: The Role of U.S. Navy Hospital Ships in Strengthening Partnerships

By Derek Joseph Licina

M.P.H. in International Health, May 2005, Uniformed Services University B.S. in Biology, May 1996, Birmingham-Southern College

A Dissertation submitted to

The Faculty of School of Public Health and Health Services of The George Washington University in partial fulfillment of the requirements for the degree of Doctor of Public Health

May 19, 2013

Dissertation directed by

Gene Migliaccio Adjunct Professor of Global Health

The School of Public Health and Health Services of The George Washington University certifies that Derek J. Licina passed the Final Examination for the degree of Doctor of

Public Health as of March 15, 2013. This is the final and approved form of the dissertation.

Rendering Mercy in Timor-Leste: The Role of U.S. Navy Hospital Ships in Strengthening Partnerships

Derek Joseph Licina

Dissertation Research Committee:

Gene Migliaccio, Adjunct Professor of Global Health and Director, Dissertation Director

Sangeeta Mookherji, Assistant Professor of Global Health, Committee Member

Cheryl Ringer, Commander, U.S. Navy, Committee Member

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Dedication

The author wishes to dedicate this dissertation to all those who have made the ultimate sacrifice on behalf of a grateful nation. You and your families are not forgotten.

Acknowledgments

The author wishes to acknowledge all those who have made this dissertation possible. First and foremost, to my loving wife and children. Kim, your support throughout our marriage has been unwavering and inspires me to be a better parent and a better man. Austin and Hannah, I hope my absence during this effort will be understood in time. You have afforded me this opportunity for which I am eternally grateful. To my parents and extended family, your love and encouragement throughout my life set me up for success. Any failures along the way were mine alone.

To my academic family, it has been a privilege to learn from you all. My

Dissertation Committee Members and Readers provided sound leadership and sage guidance throughout the dissertation journey. This product would not have been achieved without their direct support. To the George Washington University DrPH faculty and my peers, I would not have completed this program without your mentorship and friendship. I am indebted to you.

To the dissertation study facilitators and participants (especially the Timor-Leste

Ministry of Health and USAID Mission), I hope this effort meets your expectations and that you find elements of your personal contribution throughout. Thank you.

And finally, to my military family for giving me this opportunity. Knowing I sat in school while you stood watch in austere locations throughout the world is humbling. I look forward to joining your ranks again in the near future. It has and continues to be an honor to serve with you.

Abstract of Dissertation

Rendering Mercy in Timor-Leste: The Role of U.S. Navy Hospital Ships in Strengthening Partnerships

Background: U.S. foreign policy is presently and extensively tied to health initiatives, many related to the use of military assets. Despite substantial resource investment by the

Department of Defense (DoD) in hospital ship missions, their impact is unclear. The purpose of this study was to identify how Navy hospital ship missions are evaluated in the literature and understand how and why hospital ship missions influence partnerships.

Methods: The study included a systematic review of hospital ship literature and a qualitative embedded case study including key stakeholder interviews and a documentary review. The systematic literature review included peer reviewed and grey literature from eight databases representing the international community and multiple sectors. Data on the characteristics of missions related to U.S. Navy hospital ship humanitarian assistance and disaster response from 2004 to 2012 were extracted and documented. The case study used the Mercy’s Pacific Partnership mission to Timor-Leste in 2008 and 2010 as cases, with embedded units of analysis consisting of the four partnership organizations: the

U.S. government, partner nation, host nation, and non-governmental organizations.

Results: Forty-three of 1445 sources identified during the systematic literature review met the inclusion criteria. The three most significant findings were: (1) the dearth of

Navy hospital ship empirical studies; (2) the scant number of sources describing partnership impact; and (3) the complete absence of diplomatic, development, and host nation primary author publications related to Navy hospital ship missions. Fifteen themes related to how and why hospital ship missions influence partnerships emerged from 37 key stakeholder interviews and the documentary review. They included: vi

opening dialogue; developing trust, relationships, and credibility; understanding partner constraints, partner agendas, and host nation needs; developing new perspectives; sharing resources; generating innovation; achieving parent organization objectives; increasing visibility and host nation capacity; sharing leadership; and performing new activities.

Factors facilitating joining the mission included partner nations seeking a regional presence, senior executive historical relationships, and word of mouth. Enablers included historical relationships, host nation receptivity, continuity of personnel, and partner integration. The primary barrier to joining was the military leading the mission. Internal constraints included the short mission duration, participant resentment, and a lack of personnel continuity. External constraints included low host nation and USAID capacity.

Discussion: The systematic literature review supported existing criticism of the

DoDs need to more effectively measure humanitarian assistance mission impact. The embedded case study found the idea of building partnerships exists among most units of analysis. However, the results show a delay in downstream effects of the hospital ship mission on generating action and impact among the participants. Without policy, guidance, and planning documents reinforcing these constructs, achieving downstream partnership effects will remain challenging. Efforts should be made by participants to magnify the facilitators and enablers while developing mitigation strategies for the barriers and constraints identified. Doing so should increase the participants’ ability to achieve the partnership goal. Now is the time in this era of global fiscal constraints and a shift toward international partnerships for actors participating in Navy hospital ship missions to objectively measure their impact. The participants and beneficiaries of these missions as well as the American taxpayers that fund them deserve nothing less.

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Table of Contents

Dedication ...... iv

Acknowledgements ...... v

Abstract of Dissertation ...... vi

List of Figures ...... xiii

List of Tables ...... xiv

Glossary of Terms ...... xv

Chapter 1: Introduction ...... 1

Background ...... 1

Statement of the Problem ...... 2

Purpose of the Study ...... 3

Research Questions ...... 4

Study Aims...... 4

Study Design ...... 5

Theoretical Framework ...... 6

Significance of the Study ...... 7

Dissertation Format ...... 8

Chapter 2: Review of the Literature...... 9

Global Health as Diplomacy ...... 9

Hospital Ship Missions ...... 10

Pacific Partnership Mission ...... 14

Partnership Theoretical Framework ...... 18

Timor-Leste History...... 24 viii

Timor-Leste Strategic Significance ...... 27

Timor-Leste Strategic Challenges...... 31

Timor-Leste Health Status ...... 35

U.S. DoD Investment in Timor-Leste ...... 36

Chapter 3: Methods ...... 38

Overview ...... 38

Part One. Systematic Literature Review ...... 39

Study Sample ...... 39

Data Collection ...... 46

Data Analysis ...... 47

Part Two. Embedded Case Study and Documentary Material Review ...... 48

Study Design ...... 48

Case Study Method ...... 49

Study Sample ...... 51

Data Collection ...... 54

Data Analysis ...... 56

Documentary Material Review ...... 59

Study Limitations ...... 61

Protection of Human Rights...... 66

Summary ...... 67

Chapter 4: Results ...... 69

Overview ...... 69

Research Question 1 ...... 71 ix

Systematic Review Descriptive Statistics ...... 71

Bivariate Analysis of Major Categories by Mission Type...... 75

Research Question 2 ...... 79

Key Stakeholder Descriptive Statistics ...... 79

Perceived Mission Goal by Key Stakeholders ...... 82

Partnership Defined by Key Stakeholders ...... 88

Emerging Partnership Themes ...... 97

Facilitators and Enablers ...... 123

Barriers and Constraints ...... 132

Documentary Review...... 146

Summary ...... 149

Chapter 5: Discussion and Recommendations ...... 152

Overview ...... 152

Study Aim 1 ...... 154

Study Aim 2 ...... 157

Study Aim 3 ...... 170

Strengths and Limitations ...... 174

Conclusion ...... 176

References ...... 178

Appendices

Appendix A. Systematic Literature Review Coding Sheet ...... 188

Appendix B. Key Stakeholder Recruitment Scripts ...... 189

Appendix C. USAID Mission Director Endorsement Letter ...... 191

Appendix D. Timor-Leste Minister of Health Endorsement Letter ...... 192

Appendix E. IRB Approved Informed Consent Form ...... 195

Appendix F. Timor-Leste Ministry of Health Cabinet of Health Research and

Development (CHRD) Research Approval ...... 195

Appendix G. Timor-Leste MoH CHRD Informed Consent Form ...... 196

Appendix H. Interview Guide for DoD Participants ...... 197

Appendix I. Interview Guide for Non-DoD Participants ...... 199

Appendix J. Thematic Codebook ...... 201

Appendix K. GWU Human Subjects Review Board Approval ...... 202

Appendix L. Systematic Review Search Strategy and Citation Findings ...... 203

Appendix M. Sources Excluded After Eligibility Assessment ...... 206

Appendix N. Sources Included After Eligibility Assessment ...... 209

Appendix O. Perceived Goals by Unit of Analysis ...... 214

Appendix P. Partnership Definition by Unit of Analysis ...... 218

Appendix Q. Theme: Developing Relationships ...... 222

Appendix R. Theme: Developing New Perspectives ...... 233

Appendix S. Theme: Developing Credibility ...... 241

Appendix T. Theme: Sharing Resources ...... 246

Appendix U. Theme: Increasing Visibility ...... 253

Appendix V. Theme: Generating Innovation ...... 257

Appendix W. Theme: Achieving Organization Objectives ...... 264

Appendix X. Theme: Developing Trust ...... 270

Appendix Y. Theme: Increasing HN Capacity ...... 276

Appendix Z. Theme: Performing New Activities ...... 284

Appendix AA. Theme: Opening Dialogue ...... 290

Appendix BB. Theme: Understanding Partner Constraints ...... 296

Appendix CC. Theme: Understanding Partner Agenda ...... 302

Appendix DD. Theme: Understanding HN Needs ...... 307

Appendix EE. Theme: Sharing Leadership ...... 312

Appendix FF. Partnership Facilitators and Enablers ...... 316

Appendix GG. Partnership Barriers and Constraints ...... 319

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List of Figures

Figure 1. Hospital Ship Theoretical Framework ...... 7

Figure 2. Map of Timor-Leste ...... 25

Figure 3. Research Methods ...... 39

Figure 4. Embedded Case Study Design...... 51

Figure 5. Qualitative Data Analysis Process...... 58

Figure 6. Systematic Literature Review Findings...... 72

Figure 7. Partnership Themes Linked to Theoretical Framework ...... 99

Figure 8. Facilitators and Enablers Linked to Theoretical Framework ...... 125

Figure 9. Barriers and Constraints Linked to Theoretical Framework ...... 133

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List of Tables

Table 1. USNS Mercy Mission Statistics ...... 18

Table 2. Timor-Leste Health Indicators ...... 36

Table 3. Systematic Review Procedures Adapted from the Institute of Medicine ...... 41

Table 4. Databases used in Systematic Review ...... 43

Table 5. Documentary Review Material ...... 60

Table 6. Systematic Literature Review Descriptive Statistics ...... 74

Table 7. Systematic Literature Review Bivariate Analysis ...... 77

Table 8. Key Stakeholder Descriptive Statistics ...... 81

Table 9. Perceived Mission Goal Within and Between Units of Analysis ...... 82

Table 10. Partnership Definition Within and Between Units of Analysis ...... 89

Table 11. Partnership Themes Ordered by Frequency of Appearance ...... 100

Table 12. Facilitators and Enablers Within and Between Units of Analysis ...... 126

Table 13. Barriers and Constraints Within and Between Units of Analysis ...... 134

Table 14. Documentary Partnership Themes Matching Case Study ...... 149

Table 15. Partnership Questionnaire Constructs and Indicators ...... 154

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Glossary of Terms

Barrier: A factor that restricts entry to the U.S. hospital ship partnership.

Constraint: A factor that prevents the hospital ship partnership from achieving its goal.

Constraints can be either external beyond the control of the partnership or internal and inherent to the partnership.

Enabler: A factor that facilitates the success of the partnership.

Facilitator: A factor that enables entry to the U.S. hospital ship partnership.

Health diplomacy: The intersection of health and foreign policy to shape the global policy environment. In the context of the study, the use of Navy hospital ships supported by U.S. government, host nation, partner nations, and non-governmental organizations representing multiple disciplines to shape and manage the policy environment for health and diplomacy.

Impact: Positive and negative, primary and secondary long-term effects produced by the partnership, directly or indirectly, intended or unintended (Development Assistance

Committee, 2010).

Partnership: Voluntary and collaborative relationships between various parties, both

State and non-State, in which all participants agree to work together to achieve a common purpose or undertake a specific task and to share risks, responsibilities, resources, competencies and benefits (United Nations, 2003).

Chapter 1: Introduction

Background

The use of U.S. Navy hospital ships in support of humanitarian assistance missions is perceived by many within the government and international community as a pillar of health diplomacy. Although the primary mission of Navy hospital ships is to provide mobile and rapidly responsive medical capability for deployed military personnel, the secondary mission of humanitarian assistance and disaster response has been front and center since the 2004 Asian Tsunami (Department of the Navy, 2010).

The U.S. Navy hospital ship Mercy, a 1,000 bed floating hospital, was deployed to the region following the tsunami disaster and provided humanitarian assistance to over

107,000 patients (Provencher & Douglas, 2011). National polls in Bangladesh and

Indonesia after the Mercy mission in 2006 showed a significant improvement in overall opinion of the United States among host nation citizens (Terror Free Tomorrow, 2006).

Attempting to build upon this momentum, the U.S. Department of Defense deploys both the Mercy and Comfort hospital ships every two years to perform humanitarian assistance missions. The Mercy deploys in support of “Pacific Partnership” missions to nations within the Pacific while the Comfort deploys in support of

“Continuing Promise” missions to nations in Latin America and the Caribbean. The purpose of DoD hospital ship missions is multifaceted, and includes: efforts to train military personnel; build regional partnerships; support partner nation health needs; counter the ideological influence of nefarious groups; and support public diplomacy. An unstated priority of DoD is to use the hospital ship missions to bring together diverse

partners, including international NGOs and foreign country governments/military, to further US partnerships globally. The perceived positive impact of the hospital ship humanitarian assistance missions is increasing their use by the U.S. government and other states. China recently built and is now deploying their hospital ship, the Peace Ark, in support of humanitarian missions. The Peace Ark made port calls to African nations in

2010 and to Central American and Caribbean nations in 2011 (MercoPress, 2011; Taylor,

2011; Xinhua, 2010). This comes only months after the Comfort departed Central

America and the Caribbean where they supported the 2011 Continuing Promise mission.

Statement of the Problem

Every two years the Mercy and the Comfort hospital ships incorporate partner nation, host nation, and non-governmental organization personnel in their humanitarian assistance missions. DoD has invested substantial human and financial resource investment in these hospital ship missions as have other participants. However, the impact of the hospital ship mission on building meaningful partnerships remains unclear. This is largely because the focus of assessment has been on the role of the DoD in providing services for humanitarian and health needs. Professionals both within and outside of the DoD highlight the need for the military to measure the impact of all humanitarian assistance missions (E. V. Bonventre, 2008; Bourdeaux, Lawry, Bonventre,

& Burkle, 2010; Licina & Schor, 2007; Reaves, Schor, & Burkle, 2008a; Reaves, Schor,

& Burkle, 2008b). Other humanitarian actors are even critical of the DoD operating in the humanitarian space (Welling, Ryan, Burris, & Rich, 2010). The rift between humanitarian and military actors has been documented within the literature (Chretien,

2011). However, what empirical studies have yet to assess is the impact hospital ship missions have on partnerships. This study proposes to fill this gap, and provide information on the partnership-building contributions of hospital ship missions that may help bridge the rift between DoD and humanitarian actors and establish, enable, and sustain meaningful partnerships among the diverse set of hospital ship mission participants.

Purpose of the Study

The purpose of this research study was to identify how U.S. Navy hospital ship missions are evaluated and to understand how and why U.S. Navy hospital ship missions influence partnerships. A systematic review analyzing the breadth and scope of the literature informs the DoD and partner organizations how each other and the broader international community characterize and evaluate hospital ship missions. Identifying the mission types, focus areas, and study methods used in the hospital ship literature assisted in highlighted gaps in knowledge and served to inform the partnership focus of the study.

Perceived advantages and disadvantages of partnering on a U.S. Navy hospital ship mission as well as the facilitators and barriers to effective partnership were explored.

The study identified how participating organizations changed as a result of the partnership and what impact the partnership had on each organization. An embedded case study of the hospital ship Mercy mission to Timor-Leste during Pacific Partnership

2008 and 2010 (PP08 and PP10) was used. The embedded case study across two time periods provided rich information used to assess how participants change chronologically as a result of the partnership and increased the validity and generalizability of the

findings. Findings of this study informed a proposed theoretical framework for measuring partnership effects and a measurement instrument that can be used to improve future hospital ship partnership impact. The results could serve as a baseline for future multiple case studies comparing the partnership impact between the Mercy and Comfort hospital ships.

Research Questions

1. How are U.S. Navy hospital ship missions evaluated in the literature?

2. “How” and “why” do U.S. Navy hospital ship missions influence partnerships among the U.S. government, host nations, partner nations, and non-governmental organizations?

a. What were the perceived advantages and disadvantages of partnering with the

Mercy during PP08 and PP10 and why?

b. What were the facilitators and barriers to effective partnership among different

participants during PP08 and PP10 and why?

c. How did organizations change as a result of the hospital ship partnership?

Study Aims

To gain a better understanding of how and why hospital ship missions influence partnerships within and between organizations, multiple individual perspectives from the policy to implementation level were explored. This advanced the understanding of hospital ship influence on partnerships and provided new insights into the overall impact of hospital ship missions. The three study aims were:

1. To determine how U.S. Navy hospital ship missions are evaluated using the literature from 2004 to 2012.

2. To understand how and why U.S. Navy hospital ship missions influence partnerships.

3. To validate a theoretical framework that can be used to improve the measurement of partnership effects among hospital ship mission participants.

Study Design

Mixed methodology was used to derive conclusions about each of the study aims.

The study methods included a systematic review of hospital ship literature (Study Aim 1) and a qualitative embedded case study across two time periods including both key stakeholder open-ended interviews and a document review (Study Aim 2). The systematic literature review characterized the breadth and scope of the hospital ship literature. Study Aim 2 used a case study of the Mercy’s Pacific Partnership mission to

Timor-Leste in 2008 and 2010 as cases, with embedded units of analysis consisting of the four partnership organizations. The four units of analysis were: the U.S. government, partner nation, host nation, and non-governmental organizations. Key stakeholders representing each unit of analysis were interviewed using open-ended interviews. The interviews explored the experiences of each participant and their organization and were analyzed using the a priori domains in a proposed partnership theoretical framework.

These domains included: the partnership goals, advantages and disadvantages of the partnership, facilitators and barriers to joining the partnership, external and internal constraints to the partnership, organizational change, and successful partnership attributes. To complement and supplement the stakeholder interviews, a document

review of key Pacific Partnership 2008 and 2010 planning documents and other material gathered during the interviews provided historical context and insight into the culture of each participating organization. The document review substantiated data collected during the key stakeholder interviews.

Theoretical Framework

The theoretical framework that guided this research is depicted in Figure 1 and was adapted from Boydell and Rugkasa (Boydell & Rugkasa, 2007). Their conceptual model described how partnerships could serve as a mechanism for reducing inequalities in health and was based on the Realistic Evaluation approach used in evaluating partnerships (Pawson & Tilley, 1997). The theoretical framework for this study depicts how a hospital ship mission can lead to strengthened partnerships and possibly improved health outcomes in the host nation. Constraints to the hospital ship missions are considered in the theoretical model to inform mitigation strategies. Successful partnership attributes (e.g. communication and trust) were added to the framework and depicted throughout the partnership as being necessary to enable positive impact.

Furthermore, the model illustrates the benefits of partnership in a linear fashion while acknowledging the partnership process is dynamic and iterative. The model captures the benefits that may accrue throughout partnership development that are not accounted for in other models or theories (Boydell & Rugkasa, 2007). Ultimately, a positive change in both the partnerships and host nation population health could be generated as a result of the hospital ship partnership. Major elements of the theoretical framework in this study

corresponded directly to Study Aim 2. An in depth analysis of how the framework could be applied to Pacific Partnership is found in Chapter 2.

Figure 1. Hospital Ship Theoretical Framework, adapted from Boydell & Rugkasa (2007)

Significance of the Study

This is the first study to systematically assess the partnership impact of U.S. hospital ship missions. As the number of hospital ship humanitarian missions increases while the DoD budget decreases, informing the DoD of the partnership impact has never been more important. The findings of this study could support the DoD’s effort to establish, enable, and sustain meaningful partnerships. Although the study assessed partnership impact of the USNS Mercy mission in Timor-Leste (a post-conflict nation), the findings should be generalizable to other countries visited during PP08 and PP10 and

more broadly to other Mercy missions. A similar study focusing on the USNS Comfort during Continuing Promise missions in Latin America and the Caribbean could substantiate the external validity of these findings to all U.S. Navy hospital ship missions.

Finally, application of the findings to improve partnerships between the USG, foreign nations, and NGOs in contexts beyond hospital ship missions may be warranted and require further analysis. This unique opportunity could bridge the rift with humanitarian actors and establish, enable, and sustain meaningful partnerships with the U.S. DoD.

Dissertation Format

Chapter 2 reviews the literature and discusses hospital ship missions, Timor-

Leste, and partnerships. Chapter 3 describes the study design, case study method, and data collection and analysis procedures that were used during the study. The study results are presented in Chapter 4 and Chapter 5 discusses the findings and concludes.

Chapter 2: Review of the Literature

Global Health as Diplomacy

Changes in political environments and other global factors have forced nations to reconsider their foreign policies and determine how to leverage health in mitigating complex problems (Adams, Novotny, & Leslie, 2008). These problems range from political instability as seen in Latin America and Eastern Europe, failed nation-building efforts in the Middle East, to global human security threats such as severe acute respiratory syndrome (SARS) and human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS). Leveraging global health in these environments is not unique to states such as the U.S., China and Cuba, but also non-state actors like

Hezbollah in Lebanon and the Tamil Tigers of Sri Lanka that use health-interventions to meet their broader interests (Feldbaum & Michaud, 2010; Feldbaum, Lee, & Michaud,

2010). Within the international community, perceptions of improved global security, enhanced trade and development through the use of global health is serving as a catalyst to move foreign policy away from national interests and more towards global humanity

(Horton, 2007). As a result, “diplomats are moving into the health arena and more public health experts into the world of diplomacy” (Kickbusch, Silberschmidt, & Buss, 2007).

It is important to keep in mind although global health influences foreign policy, foreign policy drives what global health issues gain priority and funding (Feldbaum & Michaud,

2010). A review of senior foreign policy statements and literature used to better position global health within foreign policy found most nation states make decisions to employ global health on issues of national security and economic interests rather than on global

humanity (Labonte & Gagnon, 2010). These findings illuminate why global health programs targeting threats from bioterrorism and infectious diseases such as HIV/AIDS, avian and pandemic influenza achieve foreign policy priority over chronic diseases and injuries which contribute substantially more to the global burden of disease (Feldbaum et al., 2010; Shiffman, 2009). It is this unique fusion of health and foreign policy that is now referred to as health diplomacy (Feldbaum et al., 2010). Unfortunately, the lack of a clear U.S. government definition of health diplomacy has obscured objectives and responsibilities in this arena among different departments and agencies. Not withstanding, the employment of U.S. Navy hospital ships in support of humanitarian assistance missions is perceived by many within the government and international community as a pillar of health diplomacy.

Hospital Ship Missions

In an effort to support partner nation health sector capacity building efforts, counter the ideological influence of nefarious groups, and support public diplomacy, the

U.S. Government deploys Navy hospital ships to perform humanitarian assistance missions. Although the primary mission of the hospital ship is to provide rapid medical capability for deployed military personnel, it is the secondary mission of providing humanitarian assistance that has dominated their use the past decade (Department of the

Navy, 2010). The DoD currently maintains the USNS Mercy (T-AH 19) and USNS

Comfort (T-AH 20) hospital ships to support and conduct these humanitarian missions in the Pacific and Latin America/Caribbean regions.

The USNS Mercy originally served as an oil tanker and was converted to a hospital ship before commissioning by the Navy in November 1986. In February 1987, the USNS Mercy conducted a humanitarian mission at seven ports in The Republic of the

Philippines and South Pacific. Over 62,000 outpatient and almost 1,000 inpatients were treated. In August of 1990, the USNS Mercy was activated to support forward deployed military personnel during Operation Desert Shield. A total of 690 multinational allied force patients were seen and almost 300 surgeries conducted during the six-month mission to the Middle-East region. The Mercy would not be deployed again for another

15 years.

In January 2005, the Mercy departed the homeport of San Diego, California to provide humanitarian assistance in the South Pacific following the devastating December

2004 Asian tsunami. The DoD developed a novel public-private partnership to leverage

Non-Governmental Organization (NGO) support during the response. More than 200 civilian medical professionals from the NGO Project HOPE supported the USNS Mercy in meeting the humanitarian needs of the region (J. B. Peake, 2006; Timboe & Holt,

2006). Over 107,000 patients were treated, 466 surgeries performed, 11,555 pairs of glasses distributed and more than 6,900 dental procedures were performed in Indonesia,

Papua New Guinea, and Timor-Leste during the disaster response (Provencher &

Douglas, 2011).

Today, the USNS Mercy supports the U.S. Pacific Fleet based out of Honolulu,

Hawaii and is building upon the Tsunami experience by participating in Pacific

Partnership humanitarian missions (Department of the Navy, 2010). Pacific Partnership is an annual U.S. Pacific Fleet led multilateral engagement program that takes place in

the Pacific region. The USNS Mercy is deployed biennially in support of Pacific

Partnership. During the Mercy deployments, the U.S. DoD collaborates with interagency partners such as USAID, regional partner nations, host nations, and NGOs. Multiple planning meetings are jointly conducted prior to deployment to ensure the effective implementation of all participating organizations. Many of the partner organizations deploy on the Mercy to multiple countries of strategic interest to the U.S. over a period of approximately four months. The Pacific Partnership missions are intended to support both the DoD National Military Strategy and the U.S. National Security Strategy strategies by strengthening interagency, bi-lateral, regional, and international partnerships while providing humanitarian assistance to host nation populations (Department of

Defense, 2011; The White House, 2010; U.S. Pacific Fleet, 2011b).

Furthermore, these missions operationalize the seminal U.S. Maritime Security

Strategy published in October 2007. The strategy was jointly developed by the U.S.

Navy, U.S. Marines, and U.S. Coast Guard to strengthen emerging alliances and establish favorable global security conditions (Conway, Roughead, & Allen, 2007). The leaders of the U.S. Navy, Marine Corps and Coast Guard clearly highlight the of role globalization in shaping health among other key areas and the need to enable our partners through maritime partnerships to address these challenges. Establishing trust and confidence over time with these partners through missions such as Pacific Partnership should increase the ability of all to effectively respond during times of humanitarian crisis, disaster response, and conflict.

Hospital ship missions are not new to the U.S. government or the international community. The hospital ship USS Hope (AH-7) was commissioned by the Navy on

August 15, 1944 to render forward deployed medical care to wounded service members in the Pacific during WWII. USS Hope was operated by the Navy and augmented with

Army medical personnel. The ship supported combat operations in Japan and The

Republic of the Philippines before being decommissioned in May 9, 1946 where she remained in the custody of the War Department till 1950. Acquired by the Navy just 15 days after the USS Hope, the hospital ship USS Consolation (AH-15) also supported operations in the Pacific during WWII. With an initial mission of screening Allied

POWs off the coast of Japan during the war, the USS Consolation served as a base hospital during the Allied occupation of Japan until November 1945. The ship was called upon once again to support combat operations in Korea from August 1954 until March

1955. The USS Consolation was decommissioned on December 30, 1955 and later chartered to the People to People Health Foundation and renamed SS Hope on March 16,

1960.

The SS Hope departed for her inaugural mission to Indonesia in September 1960 in order to provide medical support and training to the Indonesian population. For the next 14 years, the SS Hope would conduct 11 voyages serving underdeveloped areas of the world. Missions included port calls in East Asia (South Vietnam), South Asia (Sri

Lanka), North Africa (Tunisia), Central America (Ecuador, Nicaragua, Colombia), South

America (Brazil and Peru), and the Caribbean (Jamaica). It took only four years after the

SS Hope was decommissioned in 1974 before another civilian organization, the NGO

Mercy Ships, would assume a similar humanitarian mission.

Mercy Ships was established in 1978 with a mission to reach developing country populations in desperate need of medical services. This NGO recognized that 21 of the

24 world’s largest cities were port cities and within just one hundred miles of these 21 cities lived two-thirds of the world’s population (Hancocks, 1995). To reach this population, Mercy Ships purchased their first vessel in 1978 and began recruiting health care professionals from around the world to provide services on the ship. The Anastasis was an 11-ton passenger ship that was converted into the world’s largest NGO hospital ship. After 29 years of service, the Anastasis was retired in 2007 and replaced by the

Africa Mercy. The new vessel remains the largest NGO hospital ship in the world and is staffed by professionals representing 30 different countries. When deployed to developing country ports, the Anastasis remains on site for 10 months to address the medical needs of the population and builds capacity of the host nation medical personnel through training programs conducted both on and off the ship. Since 1978, Mercy Ships has performed services valued in excess of $834 million and impacted over 2.9 million individuals with over 563 port visits to 53 developing nations and 17 developed nations

(Mercy Ships, 2011).

Pacific Partnership Mission

The U.S. Navy Pacific Partnership mission originated in part as a result of the

2004 Asian Tsunami U.S. government response known as Operation Unified Assistance.

National polls in Bangladesh and Indonesia after the Mercy mission showed a significant improvement in overall opinion of the United States among host nation citizens (Terror

Free Tomorrow, 2006). The U.S. Pacific Fleet sought to build upon the diplomatic goodwill generated toward the U.S. during the Tsunami response by deploying the USNS

Mercy back to the Pacific region in 2006 on a four-month humanitarian mission (U.S.

Pacific Fleet, 2011a). With 12 operating rooms and 1,000 hospital beds (80 ICU, 20

PACU, 400 intermediate care, 500 minimal care beds), the floating tertiary care facility provides services and capabilities otherwise limited or unavailable to host nation populations. Surgical procedures range from orthopedic fracture care to cleft palate and cataract repair. Additional humanitarian and civic aid programs conducted during the

Pacific Partnership mission include veterinary civic action (VETCAP), dental civic action

(DENCAP), and engineering civic action (ENCAP) programs. These programs are typically conducted in more remote locations with support from host nation Ministry of

Defense and Ministry of Health personnel. Working through, by and with the host nation is an effort by the U.S. military to increase the host nation’s credibility among the population while attempting to buttress existing national programs such as routine immunization. Reaching out to remote populations also increases the visibility of U.S. participants, which may influence their perceptions of the U.S. writ large.

During the four-month PP mission in 2006, the DoD included members of U.S. based NGOs and partner nations to provide support to the people of the Republic of the

Philippines, Bangladesh, Indonesia, West Timor and East Timor (U.S. Pacific Fleet,

2011a). Their active participation during both the planning and implementation phases of the mission was an effort to build partnerships with organizations that would likely be called upon to support future disaster response activities. Shifting priorities and approach, the U.S. Pacific Fleet sought to strengthen bi-lateral relationships with Pacific regional partners in 2007 and deployed the USS Peleliu on the inaugural “Pacific

Partnership” mission. The USS Peleliu is a large deck U.S. Navy amphibious warship that was configured for the humanitarian and civic assistance mission and augmented

with additional medical support personnel. The USS Peleliu deployed to support the humanitarian needs of the people of the Republic of the Philippines, Vietnam, Papua

New Guinea, the Solomon Islands, and the Republic of the Marshal Islands while strengthening partnerships with the host nations.

The following year, U.S. Pacific Fleet deployed the USNS Mercy for the 2008

Pacific Partnership mission in an effort to broaden NGO partnerships to include local chapters of host nations’ organizations (U.S. Pacific Fleet, 2011a). Six nongovernmental organizations and ten partner nations in conjunction with the Mercy personnel provided humanitarian assistance to the people of the Republic of the Philippines, Vietnam, Timor-

Leste, Papua New Guinea, and the Federated States of Micronesia (Chuuk State) (King &

Baker, 2010). The Navy deploys non-medical ships to provide humanitarian assistance in between Mercy supported Pacific Partnership missions. The USNS Byrd was deployed in 2009 to further strengthen partnerships during the Pacific Partnership mission. The logistic supply ship provided humanitarian aid and civic assistance to the Oceanic nations of Kiribati, Republic of the Marshall Islands, Samoa, Solomon Islands, and Tonga.

The USNS Mercy was called upon again during the PP10 mission and deployed to Cambodia, Indonesia, Papua New Guinea, Timor-Leste (the case study of this dissertation), and Vietnam with the support of 8 different partner nations and 17 nongovernmental organizations (Provencher & Douglas, 2011). During the PP10 mission, over 100,000 patients were treated, 856 surgical cases completed, 1,505 dental patients treated, 58,000 pairs of eyeglasses and sunglasses distributed, and 124 pieces of medical equipment were repaired at a value of $58 million (Provencher & Douglas, 2011; U.S.

Pacific Fleet, 2011a).

Although the patient output numbers during USNS Mercy supported missions are large (Table 1) and other projects completed during the Pacific Partnership missions perceived effective by the mission participants (e.g. distributing eyeglass), their impact on strengthening partnerships or achieving the National Military Strategy objective of

Strengthening International and Regional security is unknown. Measuring impact of activities such as hospital ship missions on partnerships where reliable data is lacking can be a challenge. Furthermore, the health outcomes for the host nation are also unknown.

How health services are prioritized and provided whether based on cost benefit analysis, return on investment strategies, or disease burden of the host nation country is also not clear. Previous studies highlight the need for DoD to measure the impact of their humanitarian assistance programs (E. V. Bonventre, 2008; Bourdeaux et al., 2010; Licina

& Schor, 2007; Reaves, Schor, & Burkle, 2008a; Reaves, Schor, & Burkle, 2008b).

Other studies are critical of DoD’s role in the humanitarian space and describe the rift between humanitarian and military actors (Chretien, 2011; Welling et al., 2010). Given the increased use of hospital ships by the Department of Defense and the U.S.

Government to bridge this rift and strengthen partnerships among these very organizations, it is important to design and implement rigorous studies to measure these impacts.

Table 1. USNS Mercy Mission Statistics

Year and Countries Supported Participants (Identified Outputs Mission in the Literature) 2010 Pacific • Cambodia • 8 Partner Nations • 100,000+ medical patients Partnership • Indonesia • 17 NGOs • 1,500+ dental patients • Palau • 58,000 pairs of glasses • Papua New distributed Guinea • 124 pieces of medical • Timor-Leste equipment repaired • Vietnam 2008 Pacific • Federated States • 10 Partner Nations • 90,000+ medical patients Partnership of Micronesia • 6 NGOs • 1,300 surgeries conducted • Papua New • 14,000 dental patients Guinea • Republic of the Philippines • Timor-Leste • Vietnam 2006 • Bangladesh • 60,000+ medical patients Humanitarian • Indonesia • 1,083 surgeries conducted Assistance • Republic of the • 19,375 immunizations Mission Philippines administered • Timor-Leste • 1,141 pairs of glasses distributed 2004 Operation • Indonesia • Project Hope – • 107,000+ medical patients Unified • Papua New 200 members • 466 surgeries conducted Assistance Guinea • 6,900 dental procedures • Timor-Leste • 11,555 pairs of glasses distributed

Partnership Theoretical Framework

Program theory provides a framework that describes the concepts, assumptions, and expectations for program structure, operation, and effect. A program theory developed in concert with all key stakeholders increases the likelihood of success in accomplishing both short and long term program objectives. Although this approach makes it challenging to reach consensus, it facilitates buy-in from all participants

(Springett & Young, 2002). Furthermore, the theory itself leads to the development of program evaluation questions that are viewed as both relevant and potentially important to all stakeholders. Through program evaluation, an organization can validate whether 18

the program implemented as planned produces the intended effects on the target populations or if program theory failure exists. On the contrary, if the key program stakeholders are unable to generate consensus in a developing a program theory, the program itself may be poorly defined or overshadowed by individual philosophies (Rossi,

Freeman, & Lipsey, 2004).

A review of Pacific Partnership literature did not yield a publicly available program theory. This may be due in part to the underlying assumptions the program has in accomplishing the goal of strengthening partnerships or an oversight of the mission planners. Although reasonable to assume collaboration among partners during a mission will result in stronger partnerships, how and why this occurs may not be fully understood through the existing implicit Pacific Partnership program theory. It is acceptable to posit individuals or organizations establish partnerships to accomplish a goal that would be more difficult to achieve in isolation (Boex & Henry, 2001). And there are many different facilitators, such as market turbulence, resource constraints, economies of scale, historical partnership involvement, international expansion, and risk sharing, among others, which influence these partnerships (Glaister & Buckley P., 1996; Lorange &

Roos, 1991). Additionally, the literature is filled with numerous attributes that define successful relationships. These include but are not limited to the following: common purpose and mission with measurable goals, continuous participation, key leader involvement, institution cultural sensitivity, mechanisms for communication and building trust, and conflict resolution (Calleson, Seifer, & Maurana, 2002; Chatman, Buford, &

Plant, 2003; Craves, Piercy, & Cravens, 2000; Spekman & Mohr, 1994).

This shortfall in program theory is not unique to Pacific Partnership. The Joint

Staff publication that provides doctrine for planning, executing, and assessing U.S. military assets in support of foreign humanitarian assistance does not have a program theory either (Department of Defense, 2009). Rather a description of measures of effectiveness is provided with suggested indicators to measure the change in individual lives within the affected host nation. Without a program theory to inform a formative evaluation of how U.S. military resources contributed to the overall U.S. government and broader international humanitarian assistance response as suggested in the summative indicators, it is difficult to assess what has truly been accomplished and how lessons observed can be institutionalized into lessons learned.

In an effort to inform a Pacific Partnership program theory, it is useful to explore partnering models found in the business and health sectors. International franchise expansion in the business sector provides a rich literature looking at drivers of organization, growth, and performance in partnerships (Dant, Kacker, Coughlan, &

Emerson, 2007; Kaufman & Dant, 1996; Michael & Combs, 2008; Shane & Spell, 1998;

Shane, 1998; Shane, 2001). When markets present opportunities, both franchisors and franchisees look for ways to establish partnerships to take advantage of the opportunities.

In this partnership, the franchisors assume resource risk in both expanding the franchise concept and transferring resources to franchisees. Franchisors look for partners that are native to and experts in the region and sector of interest (Ryans, Lotz, & Krampf, 1999).

The resulting symbiotic partnership yields a dependence or interdependence and produces commitment and trust (Kumar, Scheer, & Steenkamp, 1995). Through this commitment and trust, deleterious affects such as partner conflict is mitigated (Kumar et al., 1995).

Interdependence also has a positive effect on communication by increasing amount, frequency, and quality (Mohr, Fisher, & Nevin, 1996). It is worth noting that new partnerships may attempt to minimize initial risks and costs of new ventures. As such, they may perform below an efficient scale until the franchise grows to a point where average costs falls rendering greater profitability (Shane & Spell, 1998).

Grewel et al (2011) added to this body of knowledge by looking at the impacts of partnership on international franchise expansion to identify issues that influence market expansion and positively impact performance (Grewal, Iyer, Javalgi, & Radulovich,

2011). They incorporated franchise resources, market factors, and environmental uncertainty into a framework linking partnership with expansion and performance. Their framework suggests a partnership using entrepreneurial approaches to both knowledge use and value creation significantly influence the speed, scale, and scope of franchise internationalization. Although not explicit, many parallels can be drawn between hospital ship missions and international franchise expansion. In this example, the U.S.

DoD would be serving as the franchisor of a regional humanitarian assistance and disaster response program and facilitating the international expansion with multiple franchisees represented by public and private organizations. The DoD would “contract” with the host nation ministries who supply regional and national institutional knowledge and provide services as agreed upon in consultation with the franchisees to achieve collective goals.

Transitioning to partnership theories in the health sector, similar drivers, barriers, and impacts are observed. Public Private Partnerships (PPPs) such as the Global Alliance for Vaccination and Immunization and Program for Appropriate Technology in Health

embody characteristics listed in the aforementioned business partnership sector. It is often assumed collaboration among partners will be more effective than those conducted by individual organizations, but there is little evidence to substantiate collaboration improves health status or the health system writ large (Lasker & Weiss, 2003). These theories give rise to evaluation frameworks that are driven by evidence-based policy and practice commonly found in the health sector. The supporting frameworks are used to justify program resource investment, replicate what works and eliminate elements that do not (Boydell & Rugkasa, 2007). One theory commonly used in the health sector is the

Realistic Evaluation theory that incorporates the environment within which interventions take place to better understand what program elements work for whom and under what conditions. Building upon this theory, Boydell and Rugkasa conducted a case study looking beyond partnership process evaluation to partnership impact evaluation (Boydell

& Rugkasa, 2007). They used qualitative interviews of organization partners in two health action zones in Northern Ireland designed to reduce inequalities among the population. Their findings led to the development of a conceptual model which shows with effective processes and favorable context, partnership can lead to reductions in inequalities, specifically health.

Pulling common themes from the business and health sector partnership theories allows for linkages between the Pacific Partnership intended program outcome of strengthened partnerships as well as a proposed secondary outcome of improvements in health through the employment of the hospital ship (Figure 1). The combination of primary and secondary outcomes in this case clearly highlights the need to explicitly define both the program process theory and program impact theory. Process theory

combines the program’s organizational and service utilization plans and explains program operation while impact theory describes the causal association between the program activities and effects they produce (Rossi et al., 2004). Unfortunately, many formative evaluations focus on partnership process rather than measuring impact. But with an understanding of the drivers behind engaging in partnerships, knowing the key tenants of successful relationships, and having a program goal of strengthening regional relationships our ability to develop a useful hospital ship program theory is achievable.

Using the Pacific Partnership mission purpose found in the literature yields an explicit theoretical model (Figure 1) (U.S. Pacific Fleet, 2011b).

Major elements of the proposed hospital ship theory include identifying the public and private sectors involved and forming partnerships that build links to each organizations network outside of the partnership. It is important to acknowledge hospital ship mission facilitators are many and can range from historical relationships with the

U.S. DoD, private partner international expansion ambition, public partners building an economy of scale based on resource constraints, and/or risk sharing in the partnership venture. Once the partnership is established, members learn about each organization’s capabilities and begin to develop mutual trust through dialogue and cultural bridging.

With an increase in knowledge, understanding and trust, partnership actions shift to accommodate both individual organization and collective hospital ship mission agendas.

This in turn generates impacts such as more effective projects (e.g. medical, dental, veterinary), service delivery, and strengthened host nation capacity and legitimacy.

Positive attitudes could emerge regarding the overall hospital ship mission contribution and increase the likelihood of future U.S. partnering. During this iterative process,

hospital ship mission goals could migrate from the collective partnership into individual participant corporate objectives. Furthermore, the model depicts the benefits of partnership in a liner fashion while acknowledging the partnership process is iterative.

The model captures the benefits that may accrue throughout the partnership development that are not accounted for in other models or theories (Boydell & Rugkasa, 2007).

Ultimately, a positive change in both the partnerships and host nation population health is generated as a result of the program.

Barriers to partners joining the hospital ship mission must be considered in the theoretical model to inform mitigation strategies. External and internal environmental constraints to the partnership also can impact the partnership (Boydell & Rugkasa, 2007;

Grewal et al., 2011). External factors beyond the control of the partnership include changing and conflicting policies, resource availability, political climate, cultural perspectives, and market turbulence. Internal factors inherent to the partnership include partner conflict and the time consuming nature of collaboration between multiple partners. Early dialogue regarding the barriers to joining and constraints to the partnership is important to mitigate their impact upon the partnership. With a clear understanding of hospital ship missions, Pacific Partnership objectives, and partnership theory, the next section will describe the unique characteristics of Timor-Leste that will serve as the case study for this research.

Timor-Leste History

Timor-Leste (formerly East Timor) is a half-island nation strategically positioned in Southeast Asia with a dynamic history (Figure 2). The first contact indigenous

populations had with Portuguese traders occurred early in the 16 th century. Over the next

400 years, the island would be a Portuguese colony until ceding a portion of the west to the Dutch in 1859. Japan would occupy Timor -Leste during World War II until their defeat when Portugal regained control. After the 1974 “Carnation Revolution” i n

Portugal and their ensuing decolonization policy, a civil war ensued in August 1975 until the Democratic Republic of Timor -Leste was declared on November 28, 1975. Both

Australia and the United States supported the newly established state based on fear the island would become a communist outpost in the South Pacific (Lothe & Peake, 2010) .

A mere nine days after independence, Indonesia invaded and annexed the territory for the next 24 years. Resistance fighters led a prolonged and bloody campaign again st the

Indonesian occupation where it is thought over 102,000 Timorese died as a result of the conflict.

Figure 2. Map of Timor-Leste 1

1Source: http://en.wikipedia.org/wiki/File:LocationEastTimor.svg

In January 1999, the Indonesian government in conjunction with Portugal and the support of the United Nations offered the people of East Timor the opportunity to vote for autonomy or independence. An overwhelming 78.5% voted for their independence in August 1999. Indonesia, with support from militias within Timor-Leste, immediately destroyed 70% of the country’s infrastructure, killed thousands of citizens, and displaced hundreds of thousands as refugees in retaliation. The mass exodus of highly educated and skilled administrative officials would lead to the collapse of the newly independent government. The health sector was not immune to this demise. Hospitals and clinics were damaged and destroyed while health care professionals fled the violence resulting in the ruin of the Timor-Leste health system (Won, Ancona, Carrigan, Laverty, & Rhee,

2006). Humanitarian organizations flooded into the country and filled critical gaps in meeting food, water, and shelter needs of the population. Development agencies mobilized and sought to reestablish essential services in the war torn country. The

United Nations Security Council would install the UN Transition Authority in East Timor to run the country until a government was elected and operational in 2002.

Through pressure from Timor-Leste elected officials and the Security Council’s desired to shift resources elsewhere, a large segment of UN personnel, to include peacekeepers, departed the country in May 2005. Perceived as premature, this departure placed heavier burdens on elected officials and organizations that were not fully established and capable (Funaki, 2009). Violence would again erupt in April 2006 when tensions between the Timor-Leste security institutions, the National Police and the more neglected Defence Force, reached a tipping point. The Timor-Leste government would request the support of UN police and peacekeeping forces under the direction of the

Australian led International Stabilization Force. Forces arrived in June 2006 and the violence subsided. Although presidential and parliamentary elections ensued in 2007, smoldering internal strife continued to plague the institutional development within

Timor-Leste.

It is not within the scope of this study to analyze each aspect of transition since the 1999 vote for independence. Rather, it is to highlight the challenges host nations, partner nations, and international organizations encounter in fragile states and post conflict settings. Timor-Leste is similar to nations where DoD has, is, or will be deployed to facilitate stability through capacity building efforts and serves as a unique case for this study. Although each post-conflict situation is different, the United Nations

Joint Working Group on Transition Issues found over 40% of countries emerging from conflict eventually return to conflict (United Nations Development Group, 2004).

Understanding how to build more effective partnerships and supporting the health needs of the population in Timor-Leste through hospital ship missions may inform policies of how to mitigate the risk of post-conflict states falling back into conflict settings.

Timor-Leste Strategic Significance

Since 2000, the U.S. government has provided over $300 million in aid to Timor-

Leste (Department of State, 2011). The strategic interest of the U.S. government in

Timor-Leste according to the U.S. Embassy is to strengthen democracy (U.S. Embassy

Timor-Leste, 2012). As both U.S. and Timor-Leste histories have shown, many different factors and sectors impact democracy. To address these factors, Timor-Leste has multiple bi-lateral and multi-lateral relationships to facilitate progress in key sectors.

These include democratization and social cohesion, poverty reduction and sustainable livelihoods, and basic social services as outlined in the United Nations Development

Assistance Framework for Timor-Leste (The United Nations, 2009). Additional factors that have come to light over the past decade that may influence U.S. strategic interest in

Timor-Leste include foreign investment by communist regimes such as China and Cuba, access to the Ombei-Wetar Straits, and influence over untapped natural resources.

Following Timor-Leste elections in 2002, the Chinese government was the first to establish diplomatic ties at the Ambassador level with the newly independent country

(Embassy of the People's Republic of China, 2011). China supports Timor-Leste in economic and development assistance that spans multiple sectors to include public health, energy, agriculture, education, and defense. Infrastructure projects include the Foreign

Ministry building, Presidential Palace, Defence Ministry headquarters, as well as multiple housing units for the Timor-Leste military personnel. These highly visible projects obscure the fact that China has donated an average of $5.34 million annually since 2000, less than other developed countries, allowing them influence beyond their overall investment (Mendes, 2009). In the health sector, over 150,000 patients have been diagnosed and treated by Chinese medical teams since 2004 (Embassy of the People's

Republic of China, 2011). A hospital in the Suai District located adjacent to Indonesia was recently built by China Metallurgical Construction, one of the largest Chinese state companies (Macauhub, 2007).

China continues to pursue influence in Timor’s military and security policies.

This was highlighted by a recent bi-lateral agreement to sell two advanced military patrol boats valued at $28 million to the Timor-Leste military. The contract included training of

Timor-Leste defense force personnel in China and will likely require future Chinese financial support and technicians to maintain the boats (Mendes, 2009). This growing bi- lateral relationship may be driven by Chinese efforts to sustain Timor-Leste’s support for the one-China policy, access to the Ombei-Wetar Straits and influence over untapped natural resources – the latter two will be addressed below (Mendes, 2009). For Timor-

Leste, China provides a counter-balance to and a way of reducing Australian and

Indonesian influence in domestic matters (Mendes, 2009). Expanding trade relations and sustaining aid support from China remains a key element in Timor-Leste economic and development interests.

Another critical bi-lateral partner in the health sector of Timor-Leste is Cuba. The second President of the Democratic Republic of East Timor, Ramos Horta, nominated

Cuba for the Nobel Peace Prize in recognition of the “colossal and dignified work” of

Cuban Health professionals in Timor-Leste (Cuban Embassy, 2011). As a Nobel Peace

Prize laureate himself, Horta’s nomination brings great credibility to the laudable work accomplished by Cuba in the health sector throughout the world. Just after Timor-Leste gained independence, Cuban health professionals filled critical gaps in the health sector and began a medical exchange program with Timor medical students. By 2008, approximately 850 Timorese students were studying medicine in Cuba and nearly 300

Cuban health workers were practicing medicine in Timor (Anderson, 2008). The Cuban approach to capacity building in Timor-Leste has been different from other aid organizations. Their priority of effort is focused on long term cooperation as a matter of solidarity between populations, not driven by financial flows or leverage (Anderson,

2008). Although many Cuban physicians were assigned to the Timor-Leste National

Hospital in Dili following independence, the majority were assigned to the 13 Districts and small clinics at the sub-district level (Anderson, 2008). Increasing services provided to the rural population was the core of the Cuban rural doctor program and filled a gap in services not being met by other development organizations. As a result, positive gains were achieved in population health and overall health care access. Similarly, access and influence among the Timor-Leste population by Cuba yielded positive political gains.

Timor-Leste clearly has much to gain from investments by both China and Cuba; however, the U.S. and Australia may perceive this growing relationship as a potential threat to influence in the country and region writ large.

This perceived threat is apparent in the strategic importance of the Ombei-Wetar

Straits off the shores of Timor-Leste. Some argue gaining Timor-Leste support and access to the Straits may give rise to a new “cold war” between China and a

U.S./Australia coalition (Keady, 2006). The straits are a deep-water trough between the

Pacific and Indian Oceans essential for submarine passage through the region. Referred to as a potential “choke point” in any future conflict, unhindered access to these straits remains a strategic interest to all nations attempting to court Timor-Leste. Evidence of perceived threat also emerges between Australia and China in their role of supporting

Timor-Leste in the development of the Timor Sea oil and gas field. Current estimates value the reserves at $13 billion over the 30-year lifespan (Polk, 2010). But the natural resources that provide so much promise for Timor-Leste also generate future challenges.

Timor-Leste Strategic Challenges

Resource rich countries in Africa such as Nigeria and Guyana have not yielded the economic performance expected by the international community. Slow growth and poor GDP per capita rates plague these nations in their pursuit of development strategies

(M. Lundahl & Sjoholm, 2006). Additionally, countries with high dependency on natural resources rate lower on the U.N. Human Development Index, struggle with corruption, have a greater probability of conflict, and a larger proportion of their population living in poverty (Berdal & Wennmann, 2010; Pally, 2003). This resource and performance disparity is sometimes referred to as a resource curse for developing nations as it represents a significant impediment to development (Doraisami, 2009; Humphreys,

Sachs, & Stiglitz, 2007; M. Lundahl & Sjöholm, 2008; Morrison, 2012; Pally, 2003).

Some argue it is in the U.S. national security interest to help nations tackle the resource curse in an effort to reduce strife, address poverty, and minimize political instability caused by this pattern (Pally, 2003).

In the case of Timor-Leste where 95% of the state budget originates from oil and gas sector and $13 billion in reserves is projected to be earned over the 30 year lifespan of the Timor Sea oil and gas field, these challenges could materialize (Polk, 2010; The

World Bank, 2011a). Timor-Leste is addressing the challenges through involvement in the Extractive Industry Transparency Initiative (EITI) where they were the first country in Asia to achieve compliance status in July 2010 (EITI, 2011). The EITI was established in 2003 and is a global effort to strengthen the governance of resource rich countries by improving accountability and transparency through the full publication of extractive company payments and government revenues. The implementation of EITI

has yield positive benefits for participating countries, extractive companies, investors, and civil society. Furthermore, the evolution of EITI is directly related to the global acceptance of transparency in mitigating the resource curse – a positive outcome of their efforts (Haufler, 2010). In Timor-Leste, recent action taken by the government to use existing oil revenue to kick-start the non-oil economy will support efforts to strengthen the economy, improve security, and nurture the democracy of Timor-Leste (Polk, 2010).

Although progress is being made in addressing the potential natural resource challenges, a rapidly expanding young population in Timor-Leste could adversely impact efforts to shore up democracy.

The correlation between a large youth-bulge in a population and a high risk of political violence and civil strife is strong (Leahy, Engelman, Vogel, Haddock, &

Preston, 2007; Mesquida & Wiener, 1996; Urdal, 2006). Recent political violence in the

Middle East and North African regions further supports these findings. With 50 percent of the Egyptian population under the age of 25 and over 90 percent of the unemployed being youth, the conditions were ripe for protest in 2011 and led to a regime change after

30 years of rule (Roudi-Fahimi, El Feki, & Tsai, 2011). Similar demographic trends are seen in Timor-Leste (World Bank, 2008). The 2009-2010 Demographic and Health

Survey in Timor-Leste found an age structure typical of a young population with a high fertility rate. The survey results indicated 61 percent of the population, 11 percentage points higher than Egypt, is under the age of 25 (National Statistics Directorate, 2010).

Additionally, the total fertility rate for Timor-Leste is 5.7 births per women. This rate is the highest in all of South Asia (tied with Afghanistan) (Roudi-Fahimi et al., 2011). As a result, Timor-Leste has the fastest growing young population in Asia, and almost the

fastest in the world (World Bank, 2008). Using these rates, the current Timor-Leste population of 1.2 million will almost double by 2025 with an estimated 1.9 million people. The booming youth population and extremely high fertility levels could lead to political turmoil in Timor-Leste.

Fertility levels are inversely related to women’s level of education, availability of family planning services, and wealth quintile (National Statistics Directorate, 2010).

Other factors such as fertility preferences, unplanned fertility, and infant mortality impact fertility levels. Directly correlated to the high fertility levels in Timor-Leste is a high level of maternal mortality. Maternal deaths accounted for 42 percent of all deaths to women age 15-49 with an overall maternal morality ratio of 557 deaths per 100,000 live births (National Statistics Directorate, 2010). This is equivalent to 6 deaths per 1,000 live births and is considered high compared to many developed countries. The bulging population growth and high maternal mortality will place a substantial burden on public services to include healthcare.

Within the economic sector, job creation will likely not keep pace with demand of this younger population thereby further exacerbating the struggling economy. The World

Bank estimates even if the number of jobs available doubles in the next decade, the number of unemployed will outpace it at 150 percent (World Bank, 2008). Unmet demands in domestic food production and environmental degradation as a result of the rapid population growth will further impact economic productivity. With an urban population projected to double by 2020 and triple by 2030, urban infrastructure and facilities will have to grow 4-5 years annually for decades just to maintain the current

levels of services (World Bank, 2008). Population growth and ensuing unmet demands in Timor-Leste could potentially give rise to unrest.

Shifting from authoritarian rule to democratic societies, similar dissent can occur as a result of a youth-bulge. A study looking at the impact a youthful age structure can have on democracy suggests it can both constrain and destabilize democracy (Cincotta,

2009). Citing examples of Colombia, Ecuador, Fiji, Papua New Guinea among others where liberal democracies emerged before seeing a decline in the youth bulge, Cincotta highlights the regimes failed to stabilize and ultimately retracted to less democratic traditions and institutions of governance. But there is reason to remain optimistic. As the youth bulge dissipates, relative political calm ensues and positive externalities are experienced as a result of a “demographic dividend” (Cincotta, 2009).

The demographic dividend is realized when mortality and fertility rates transition sequentially from high to low and stimulate economic development. On the contrary, poor health can stymie the demographic transition and result in higher mortality due to disease and illness thereby increasing fertility levels – a poverty trap that greatly hinders economic progress (Bloom & Canning, 2000). As Bloom reported, “poor health is more than just a consequence of low income, it is also one of its fundamental causes. To be sure, health and demography are not the only influences on economic growth, but they certainly appear to be among the most potent” (Bloom & Canning, 2000). In an effort to realize a demographic dividend within the next decade in Timor-Leste, the government must capitalize on the opportunity. Programs to lower maternal mortality rates should be followed by family planning services to push down fertility rates. Both effects will increase the number of women available to enter the workforce and directly improve their

health status (Bloom, Canning, & Sevilla, 2003). The Ministry of Health in Timor-Leste is working through bilateral and multilateral organizations to address these two critical issues. Furthermore, a decrease in the dependency ratio and an increase in savings at the individual family level will translate into economic gains from the individual to the national level. The 2011 World Development Report found on average, conflict and post-conflict nations like Timor-Leste take a full generation (15-30 years) to transition out of fragility and become more resilient states (The World Bank, 2011b). Based on

Timor-Leste’s current progress, there is reason to remain optimistic. Through proper support and engagement, effective strategies can be put in place to mitigate some of the risk in each of these sectors and lead to a prosperous democratic state.

Timor-Leste Health Status

The health needs of the Timorese population are significant and driven primarily by a lack of capacity (Table 2) (National Statistics Directorate, 2010). These findings include only 1 in 5 births delivered in a health facility and a maternal mortality ratio of

577 per 100,000 live births – one of the highest in the world. Both the under-five and infant mortality rates (63.7 and 44.6 per 1,000 live births) are almost twice as high as the

Southeast Asian regional average. Further compounding these figures is a total fertility rate of 5.7 births per woman, the highest in all of South-East Asia and Asia (together with

Afghanistan). Only 53% of children 12-23 months of age are fully immunized. A staggering 58% of children under 5 are stunted and 45% underweight. These statistics highlight the universal need to scale up humanitarian assistance following conflict in order to improve the quantity and quality of health care, education, and employment of

host nation populations (Burkle, 2010). Understanding the unique history, strategic significance, and strategic challenges of Timor-Leste clearly highlights why this country was chosen for this case study.

Table 2 . Timor-Leste Health Indicators

MDG Health Indicator Timor-Leste 1 SE Asia Regional Developing Regions Average 2 Average 2 Maternal mortality ratio 557 160 290 Under five mortality rate 63.7 36 66 (per 1,000 live births) Infant mortality rate 44.6 29 48 (per 1,000 live births) Proportion of deliveries 30 72 65 assisted by skilled birth attendant Under five 52 18 23 under weight (percentage) Contraceptive prevalence 21 62.3 61.3 rate Percentage of married 30.8 10.9* 11.3* women with an unmet need for family planning 1As reported in the 2010 Timor-Leste DHS 2As reported by the World Health Organization using 2009 data unless noted by an * for 2008 data

U.S. Department of Defense Investment in Timor-Leste

The U.S. DoD has invested heavily in humanitarian assistance for Timor-Leste.

The USNS Mercy made Pacific Partnership port calls in 2006, 2008, and 2010 with additional U.S. Navy ships providing humanitarian assistance (primarily health related) between these years. U.S Air Force assets also provided humanitarian assistance to

Timor-Leste during Operation Pacific Angel in 2009 and 2011. It would be useful for

DoD and the U.S. government to better understand the impact of these individual

missions and collective efforts. In doing so, priorities of effort to fill identified health needs in Timor-Leste with unique military service capabilities could be established.

Findings of this study could serve as a baseline for future studies to compare resource inputs associated with the different DoD missions conducted in Timor-Leste to intended outcomes. A cost benefit analysis study would allow the DoD and U.S. government to determine where the greatest return on investment is realized.

This study informs the U.S. government of the partnership impact of the USNS

Mercy mission to Timor-Leste during PP08 and PP10. The findings are generalizable to other countries visited during PP08 and PP10 and more broadly to other Mercy PP missions. A similar study focusing on the USNS Comfort during Continuing Promise missions in Latin America and the Caribbean could substantiate the external validity of these findings to all U.S. Navy hospital ship missions. As the number of hospital ship secondary missions increase (humanitarian assistance) while the DoD budget decreases, informing the DoD of the partnership outcomes has never been more important. Chapter

3 describes the study design, data collection methods and analysis procedures used during the study.

Chapter 3: Methods

Overview

The purpose of this study was to identify how U.S. Navy hospital ship missions are evaluated in the literature and understand how and why hospital ship missions influence partnerships. To answer these questions, the study was structured in two parts

(Figure 3). Part one was a systematic literature review and Part two an embedded case study across two time periods. The systematic review analyzed the breadth and scope of the literature to inform the DoD and partner organizations how each other and the broader international community characterize and evaluate hospital ship missions. By identifying mission types, focus areas, and study methods used in the hospital ship literature, the systematic review highlighted gaps in knowledge and informed the case study. The case study focused on the hospital ship missions to Timor-Leste in 2008 and 2010 with embedded units of analysis consisting of four partnership organizations: U.S. government, partner nations, host nation, and non-governmental organizations. The embedded case study across two time periods provided rich information to assess how participants changed chronologically as a result of the partnership and increases the validity and generalizability of the findings. Key stakeholders representing each unit of analysis were interviewed using open-ended interviews. The interviews explored the experiences of each participant and were analyzed using a priori domains from the proposed partnership theoretical framework. These domains included the goals, advantages and disadvantages of the partnership, facilitators and barriers to joining the

partnership, external and internal constraints to the partnership, organizational change, and successful partnership attributes. This chapter describes the study sample, data collection, and data analysis procedures for the systematic literature review and case study. It concludes with a description of study method limitations and how human rights were protected during the research.

Figure 3. Research Methods

Part One. Systematic Literature Review

Study Sample

The overall purpose of the systematic review (SR) was to identify how U.S. Navy hospital ship missions were evaluated in the literature. Additionally, the SR informs the

DoD and partner organizations how each other and the broader international community describe hospital ship missions. Recognizing various organizations conduct SR for different purposes such as The Cochran Collaboration and healthcare to The Campbell

Collaboration and social interventions, this SR used standards published by the Institute of Medicine (IOM) of the National Academies and Centre for Reviews and

Dissemination (Campbell Collaboration, 2012; Cochrane Collaboration, 2012; Institute of

Medicine, 2011). The IOM standards were established based on a congressional mandate in 2008 to improve the quality and usability of SR in the U.S. primarily in developing clinical practice guidelines. A committee was established and charged to assess existing methodological standards and recommend a method set to assure objective, transparent, and scientifically valid SRs. The IOM committee based their findings on scientific evidence and guidance from multiple expert organizations including, but not limited to, the Agency for Healthcare Research and Quality, the Centre for Reviews and

Dissemination, and the Cochrane Collaboration (Institute of Medicine, 2011).

The published IOM report recommended 21 standards and 82 elements of performance to address the entire SR process from formulating the topic to developing the final report. Although it was impossible in this study to obtain information in every step of the IOM process, being transparent throughout the SR facilitates understanding and replication. Members of the IOM committee themselves acknowledged the daunting tasks outlined in their SR procedures (Institute of Medicine, 2011). However, they recommend researchers use their best judgment when resources are inadequate or some steps inappropriate for the research question of interest. Key IOM standards adapted to meet the SR process for this study are listed in Table 3. The SR occurred from March to

May 2012 and was conducted electronically by the study PI in Washington, D.C..

Table 3. Systematic Review Procedures Adapted from Institute of Medicine

Steps Procedures Step 1. Finding Conduct a Comprehensive Systematic Search and assessing • Work with the GWU librarian to plan the search strategy individual studies • Design strategy to address hospital ship and Pacific Partnership missions • Search bibliographic databases Take action to address potentially biased reporting of research results • Search grey-literature databases Screen and select studies • Include or exclude studies based on the protocol’s pre-specified criteria • Screen titles and abstracts of all articles and then read the full texts of articles identified in initial screening Document the search • Provide a description of the search strategy, including the date of every search for each database, web browser, etc. Step 2. Managing Extract critical data (qualitative and quantitative from each study) data collection • General Info: Author, title, type of publication (book, journal, etc), country of origin, author affiliation (public or private sector) • Study Characteristics: Mission type (HA, DR), focus area (medical, dental, vet, etc), study design (quantitative, qualitative, mixed) • Study Setting • Outcome Results: Construct measured Step 3. Reporting Prepare final report using a structured format Systematic Review • Include a report title* • Include an abstract* • Include an introduction (rationale and objectives)* • Include a methods section. Describe the following: Research protocol* • Eligibility criteria (including and excluding studies in the systematic review)* • Databases and other information sources used to identify relevant studies* • Search strategy* • Study selection process* • Data extraction process* • Information to be extracted from included studies* • Methods to appraise the quality of individual studies* • Methods of synthesizing the evidence (qualitative and meta-analysis*) Results section • Study selection process* • List of excluded studies and reasons for their exclusion* • Qualitative synthesis • Meta-analysis of results, if performed (explain rationale for doing one)* • Tables and figures Discussion section • Summary of the evidence* • Strengths and limitations of the systematic review* • Conclusions for each key question* • Gaps in evidence and future research needs

In Step 1 of the SR, a comprehensive search was conducted. A through and unbiased compilation of all relevant studies is described as a key element in a SR and without it, the literature identified may not represent the true population of studies completed (Rothstein, 2009). To minimize publication and selection bias in searching for hospital ship literature, multiple sources of information were explored in a thorough, objective, and reproducible manner. This effort was necessary as hospital ship missions are multidisciplinary in nature and may result in information sources produced by different sectors (e.g. health, education, and security). Source material was identified through the systematic search of the following eight databases: Cochrane Central

Collection, PubMed, ProQuest, Public Affairs Information Services (PAIS) International,

Scopus, and the Thomson Reuters Web of Knowledge (Table 4). These databases capture published and unpublished (grey literature) material representing the international community and multiple sectors to include health, education, social sciences, and the humanities. Grey literature in these databases includes conference abstracts and proceedings, research reports, technical reports, policy papers, and other unpublished material.

Table 4. Databases used in Systematic Review

Database Type Description Cochrane Central Register of Bibliographic Database Most comprehensive source of controlled Controlled Trials (CENTRAL) trials in medicine. Contains over 500,000 bibliographic references to controlled trials and other health care interventions as of March 2012. Includes both published and unpublished sources in English and other languages Index Medicus (MEDLINE) Bibliographic Database The National Library of Medicine’s database contains over 19 million references to journal articles from the 1950s to present. As of March 2012 over 5,600 journals in 39 languages indexed. Military & Bibliographic Database Current news pertaining to all military Government Collection and Grey Literature branches, this database covers about 400 titles, with full text of nearly 300 journals and periodicals and 245 pamphlets. PubMed Bibliographic Database More than 21 million citations from biomedical literature from MEDLINE, life science journals, and online books as of March 2012. Includes up-to-date citations not yet indexed in MEDLINE and additional records from journals not indexed in MEDLINE. ProQuest Dissertation and Thesis Most extensive list of North American Database theses and dissertations. Over 2 million doctoral dissertations and master theses from 1861 to the present. Public Affairs Information Bibliographic Database More than 668,000 journal articles, Services (PAIS) International and Grey Literature books, government documents, grey literature, research reports, conference reports, publication of international agencies, and other material from 1972 to the present as of March 2012. Scopus Bibliographic Database The largest abstract and citation database and Grey Literature containing both peer-reviewed research literature and quality web sources. With over 19,000 titles from more than 5,000 international publishers, 18,500 peer- reviewed journals (including 1,800 Open Access journals), 425 trade publications, 325 book series, 250 conference proceedings, over 46 million records. Thomson Reuters (formerly ISI) Bibliographic Database Includes 100 years of fully indexed Web of Knowledge and Grey Literature journal articles, international conference proceedings, pre-published content and other information from the sciences, social sciences, arts and humanities.

The key research concept was partnerships as it related to hospital ship missions using an embedded case study of Timor-Leste during PP08 and PP10. Based on a perfunctory search of the literature related to hospital ship partnerships that yielded a very low number of possible sources, two broader concepts were searched. These concepts were hospital ships (the resource of interest) and Pacific Partnership and

Continuing Promise (the humanitarian missions of interest). Due to the range of databases being searched and the various organizations that supply the information, unique search strategies were developed to account for different terminology and software packages of each. The two concepts of interest were represented in different databases using related terms such as: USNS Mercy/Comfort, hospital ship

Mercy/Comfort, Navy medical ship, hospital ship, medical ship, Pacific Partnership, and

Continuing Promise. These terms were searched using free text (natural language) and controlled vocabulary (database specific vocabulary assigned by indexers)

(Hammerstrom, Wade, & Jorgensen, 2010). The PI broadened and narrowed the original search terms using each database thesaurus. Terms within each concept were joined using the Boolean ‘OR’ operator to ensure sources containing at least one of the source terms were retrieved (Hammerstrom et al., 2010). The search strategy was documented and included the title of the database, date of the search, years covered, description of search terms used, and number of citations identified.

Search results were screened based on a priori inclusion criteria. All sources directly related to U.S. hospital ship missions from 2004 to 2012 were included and imported into RefWorks 2.0, a web based bibliographic management software package

(RefWorks, 2010). This time period captured all U.S. Navy Ship Mercy and Comfort

hospital ship missions that included partnerships in support of humanitarian assistance and disaster relief missions. Both ships conducted humanitarian assistance missions within the Pacific and the Latin American and Caribbean regions during this timeframe.

Additionally, the Mercy responded to the Asian Tsunami in the Pacific during 2005 and the Comfort responded to the Haiti earthquake in 2010. This restriction also encompassed the USNS Mercy humanitarian missions to Timor-Leste in 2006, 2008, and

2010. The inclusion criteria allowed for themes and best practices captured in the literature to better inform the hospital ship partnership theoretical framework. Any themes not previously identified in the framework were used to shape the interview guide.

Documents meeting the inclusion criteria were screened using a two-stage approach. First, titles and abstracts were screened using the inclusion criteria. Second, the full-text of sources passing the first screen were reviewed to ensure the material was relevant to the study. The IOM recommends a minimum of two screeners for the SR to reduce the likelihood of relevant studies being omitted (Institute of Medicine, 2011).

Due to budget constraints, the PI was solely responsible for screening and had a vested interest in ensuring all sources meeting the inclusion criteria were identified. A Preferred

Reporting Items for Systematic Review and Meta-Analyses ( PRISMA) flow chart was used to document the number of sources remaining after each step of the screening process (Moher, Liberati, Tetzlaff, Altman, & PRISMA Group, 2009). Sources meeting the inclusion criteria and relevant to the study were critically analyzed and relevant data extracted in accordance with the data collection section below.

Data Collection

In Step 2 of the SR, critical data was extracted from each source meeting the inclusion criteria. Qualitative and quantitative data were extracted and coded in STATA

11.2 using the form in Appendix A. Employing this standard data extraction form minimized data entry errors (Institute of Medicine, 2011). Data collected included:

• year of publication;

• country of origin (foreign or domestic);

• type of publication (journal, book, chapter, dissertation, thesis, technical report,

conference proceedings);

• author affiliation (public sector including health, security, diplomacy,

development or the private sector including profit or not for profit);

• mission type (humanitarian assistance including Continuing Promise and Pacific

Partnership or disaster response including the Asian tsunami or Haiti

earthquake);

• primary focus area (exercise/training, medical care, dental care, veterinary care,

partnerships/collaboration); and

• research methodology (quantitative, qualitative, or mixed methods).

Quantitative methodology was further coded as experimental, quasi-experimental and non-experimental. Qualitative methodology was further coded as narrative, phenomenology, grounded theory, ethnography, or case study. Mixed methodology was coded if both quantitative and qualitative methods were used. Articles not using any of

these research methods were categorized as other (e.g. editorials). Finally, the study setting and outcome results in terms of the major construct measured were coded.

To further minimize reporting bias, duplicate publications from the same study were linked together and included only once in the SR analyses (Institute of Medicine,

2011). Although the IOM recommends using a minimum of two researchers to extract data pertaining to healthcare interventions, the PI was solely responsible for extraction due to funding constraints.

Data Analysis

Descriptive statistics were calculated for each critical data variable using univariate analysis and between major categories using bivariate analysis. The major categories included country of origin, type of publication, author affiliation, mission type, primary focus area, research methodology, study setting, and outcome results. To determine which organizations are reporting on humanitarian assistance and disaster response missions, author affiliation by mission type was calculated. In order to gain an understanding of the types of publications generated by the different participating organizations, author affiliation by publication type was calculated. The proportion of medical, dental, veterinary, partnership, and training publications by mission type and author affiliation was also calculated. To identify the various types of publications generated as a result of humanitarian assistance and disaster response missions, type publication by mission type was calculated. Finally, to understand how the humanitarian assistance and disaster response publications vary by research methodology, mission type

by research method was calculated. Statistical analysis occurred from May to June 2012 and was conducted using STATA 11.2 software.

Part Two. Embedded Case Study and Documentary Material Review

Study Design

The goal of this study was to describe how and why U.S. Navy hospital ships influence partnerships among U.S. government, partner government, host nation government, and non-governmental organizations. A qualitative study design was used to fill this information void identified in the SR. Qualitative study designs are ideal for research questions that require the understanding of participants’ views (Green &

Thorogood, 2009). Key elements of qualitative research such as the researcher as a key instrument, the use of multiple sources of data, and inductive data analysis were used in this study (Creswell & Creswell, 2007). The PI collected data using key stakeholder interviews and a documentary review. Open-ended questions were used to collect participant views of the hospital ship mission and across the major partnership theoretical framework domains. This approach empowered participants to share their personal experiences of the partnership. Data analysis used a sequence of interrelated steps including reading, coding, displaying, reducing, and interpreting the data (Ulin,

Robinson, & Tolley, 2005).

Case Study Method

The specific type of qualitative design is driven by three conditions: 1) the type of research question posed, 2) the extent of control an investigator has over actual behavioral events, and 3) the degree of focus on contemporary versus historical events

(Yin, 1993). First, in this study we were interested in “how” and “why” hospital ship missions impact partnerships. Case studies provide a distinct advantage when answering

“how” and “why” research questions and are routinely employed in the social science disciplines to include public health (Yin, 2009). How and why questions are more explanatory in nature and can be answered using interviews of persons directly involved in either the event or program of interest. Interviews also provide a unique source of evidence not included in other research methods. Secondly, this research did not require control of behavioral events as seen in experimental study methods. This too is consistent with case study methodology. Finally, the research focused on contemporary hospital ship missions. Case studies are the preferred design when examining contemporary events and when relevant behaviors cannot be manipulated. Having met the three conditions for case study methodology, the decision was made to follow this method.

The case study is used in many different circumstances to expand the knowledge related to many phenomena and sectors. Phenomena can range in hierarchy from the individual to organizational level and vary by sector. A unique element of case studies when compared to other qualitative methods is the role of theory development prior to conducting data collection (Yin, 2009). The theory serves as a blueprint for the research study and facilitates the data collection phase. Additionally, an appropriately developed

theory serves as the level at which generalization of the findings can occur (Yin, 2009).

In this study, generalization can be made toward other countries where the Mercy deployed as part of PP08 and PP10 or more broadly, to missions where the USNS

Comfort may deploy in the future. Furthermore, generalization of partnership findings could be made toward other post-conflict nations where the USG may attempt to build partnerships among similar actors to achieve health or public diplomacy objectives.

Timor-Leste is a good case study based on the unique recent post-conflict status and a country that has been visited by the USNS Mercy on four occasions since 2004.

However, the historical context in Timor-Leste preceding the 2008 and 2010 missions may require adaptation of the theory to countries being engaged for the first time. These generalizations are not spontaneous, but if tested and similar results are found, this provides external validity to the theoretical framework and study findings.

This study used both open-ended interviews with key stakeholders and a review of documentary materials provided by the study participants as sources of evidence.

Using multiple sources of evidence is another robust element of case studies. These sources may include documentation such as memorandums of understanding and agreement, archival records, interviews, direct observations, participant-observation, and physical artifacts.

Timor-Leste represented a unique case (recent post-conflict nation and consistently visited by the Mercy since 2004) among all countries visited by the Mercy during the PP08 and PP10 missions. Within case study methodology, there are single and multiple case designs. This single case study design met the conditions for testing the hospital ship partnership theory and can confirm, challenge, or extend the theory (Yin,

2009). Embedded within this unique single case are multiple participating organizations that served as the units of analysis. The four embedded units were the U.S. government

(USG), partner governments (PN), host nation government, and non-governmental organizations (NGO) (Figure 4). These subunits presented further opportunity for extensive analysis in the single case (Yin, 2003). This ensured all aspects of the partnership were revealed and understood both within and between the participating organizations (Baxter & Jack, 2008). Collectively, this qualitative study design is know as an embedded case study design across two time periods (Yin, 2009).

Figure 4. Embedded Case Study Design

Context

Case

USG PN

HN NGO

Note: U.S. government (USG), partner governments (PN), host nation government (HN), and non-governmental organizations (NGO)

Study Sample

Interviews are a key component of qualitative research which allow individuals to share in rich detail their perceptions, understanding, and meanings regarding their

experience in the partnership (Neuman, 1997). The objective of the key stakeholder open-ended interviews was to ensure all PP08 and PP10 partner organizations were represented and interviewed until data saturation was reached. Open-ended questions allowed the researcher to follow the line of inquiry related to the theoretical framework while putting forth “nonthreatening” questions to the study participants (Yin, 2009).

Sampling occurred at the individual level and represented the four units of analysis. The specific study target population included personnel serving at strategic (policy), operational (planning), and tactical (implementing) levels. Incorporating participants from the diverse range of partners representing different levels of involvement during the two missions increased the richness and generalizability of the findings between each unit of analysis and among the different countries visited during the missions.

Representatives from the U.S. and Timor-Leste involved in both PP08 and PP10 were interviewed. Partner nation and NGO representatives from PP08 reflected those with the longest enduring Mercy hospital ship humanitarian assistance mission participation. Representatives from PP10 reflected those with the shortest participation.

This effort allowed for an assessment of changes in partnership within the units of analysis across missions as well identifying factors that are likely to change for new partner nation and NGO participants in the future.

Contact information for individuals representing each of these organizations during the PP08 and PP10 missions was obtained from military planners. Individuals were contacted via telephone or email and invited to participate in the study using standard recruitment scripts (Appendix B). Attachments to the formal email included letters of endorsement for the study from the USAID Mission Director and Minister of

Health for Timor-Leste as well as the informed consent form. (Appendix C, D, E). If the individual did not meet the study inclusion criteria, contact information for another key stakeholder within their organization was requested and email invitation sent.

Using purposeful sampling, one-on-one, open-ended interviews were conducted with key stakeholders (Miles & Huberman, 1994). The purposeful sampling strategy is unique to qualitative research and defined as selecting individuals for the study because they can purposefully inform the research question of interest (Creswell & Creswell,

2007). Additional contacts were obtained and pursued as part of a snowball sampling strategy with the original key stakeholders. This strategy ensured information-rich participants were pursued and interviewed until information saturation was reached.

When in-person interviews were not practical, telephonic interviews were conducted. Although telephonic interviews precluded the primary investigator from viewing non-verbal actions, verbal responses were captured in full using an audio recorder and detailed field note taking. Audio recordings were sent to a contractor for verbatim transcription and final word documents cross-checked with field notes for accuracy. To prevent language barriers and loss of information through translation, all participants were English speaking. Lacking common language in qualitative research is particularly problematic where emotional, cultural, and verbal implications may be lost in translation. This restriction did not impact any of the participating individuals or organizations as they spoke English as either a primary or secondary language.

Data Collection

Key stakeholder interviews were conducted from July to December 2012. In person interviews occurred in the greater Washington, D.C. area throughout the study and in Dili, Timor-Leste during the month of August. Interview participants in Timor-Leste were coordinated in conjunction with the USAID Mission and Ministry of Health. Upon arrival to Dili, the PI briefed the research study to the Timor-Leste Ministry of Health,

Cabinet of Health Research and Development (CHRD). Formal research approval was granted by the CHRD and Informed Consent Form modified for use with Timor-Leste participants (Appendix F and G). Requests, both email and in person, for F-FDTL participation were routed by the PI through the U.S. Embassy Timor-Leste, Senior

Defense Official. Unfortunately, no support was provided in facilitating this request.

The PI used contacts obtained through the Ministry of Health to reach out to the F-FDTL.

Contact was made and the PI met with a F-FDTL PP10 participant at the Ministry of

Defence headquarters building in Dili. The request to conduct an interview was made; however, the F-FDTL was not authorized to speak to the PI until the research study was cleared through the Ministry of Defence. The earliest date to brief their Chain-of-

Command and obtain approval was after the PIs departure from Timor-Leste. The

USAID Mission facilitated and coordinated multiple interviews between the PI and personnel representing various local NGOs.

The PI used an open-ended interview method. This method established the line of inquiry, but the interviewee’s response dictated what information was produced about the topic (Yin, 2009). This method provided more autonomy in data collection than structured interviews and better time management when compared to informal

interviews. An interview guide composed of open-ended questions was used to obtain stakeholder perspectives (Appendix H and I). This style of questioning allowed the participant to fully express their views related to the line of inquiry without influencing their response.

The PI initiated the interview by confirming the participant read and understood the informed consent form. Participants were given the opportunity to ask any questions.

A copy of the informed consent form was provided to each participant. Non-Timorese participants willingness to participate in the research study was implied if they proceed with the interview. Timorese participants were required to sign the CHRD Informed

Consent Form (Appendix G). Next, the PI started the interview using the interview guide. Participants were asked open-ended questions in accordance with the IRB approved interview guide. Follow-on probing questions were used to elicit additional information on the topic of interest. The final question allowed the participant to mention anything related to the partnership that was not previously discussed. Participant background information was collected at the conclusion of the interview. Each interview took approximately one hour to complete.

Audio recordings of each interview were sent to the approved transcription contractor coordinated by the PI through the U.S. Army Contracting Agency Southern

Region, Fort Sam Houston, TX. The U.S. Pacific Command (USPACOM) through the

Overseas Humanitarian Disaster Assistance and Civic Assistance program provided funding for this service, which was part of a broader approved research project nomination. The funds were transferred from USPACOM to the U.S. Army Contracting

Agency Southern Region and transferred to the contracting agency using existing

protocols. The contractor transcribed each audio recording verbatim using Microsoft

Word. Each completed interview transcript was reviewed and crosschecked with field notes taken by the PI to validate transcription accuracy. Once the interview content was validated, the PI imported the transcripts into QSR International NVivo 10 software for analysis.

The informed consent form and interview guide were pilot tested on a trial participant similar to those in the actual study. The individual participating in the pilot test added valuable recommendations for strengthening the data collection tools (Ulin et al., 2005). The form and guide were tested as they would be used in the study to ensure clarity, purpose, and confidentiality. Statements and questions were modified to ensure adequate knowledge of purpose, expectations, and possible risks were clear (Ulin et al.,

2005). The pilot test took place in Washington, D.C. in June 2012.

Data Analysis

Data analysis in qualitative research can take many different approaches, strategies, and forms. Four commonly used approaches in qualitative health research data analysis include thematic content analysis, grounded theory, framework analysis, and narrative analysis (Green & Thorogood, 2009). Four strategies used in data analysis described by Yin include relying on theoretical propositions, developing a case description, using both qualitative and quantitative data, and examining rival explanations

(Yin, 2009). Although each approach and strategy has its own strengths and weaknesses, this study used a theoretical proposition strategy. This strategy was founded on the premise that the embedded case study is based on theoretical propositions originating

from a theoretical framework that were reflected in the original research questions. Yin highlights theoretical propositions stemming from “how” and “why” questions are extremely helpful in guiding case study analysis (Yin, 2009).

What each form and strategy in qualitative data analysis have in common is the reduction of data into themes through the use of coding to finally represent the data in figures, tables, or discussion (Creswell & Creswell, 2007). This study used a data analysis process designed for qualitative public health studies (Ulin et al., 2005). The process depicted in Figure 5 was adapted from Huberman and Miles and consists of a series of interrelated steps in data analysis: reading, coding, displaying, reducing, and interpreting. Immersion with the data occurred during the process of reading all interview notes and transcribed interviews. This was an iterative process that began during data collection and early data analysis. Emerging themes were identified and tentative explanations developed. Patterns started to emerge in the themes and relationships between the units of analysis. During the data collection and early analysis processes, the meanings of these themes as defined by the study participants took shape

(Ulin et al., 2005). Once the material and themes were intimately familiar, the coding process commenced.

Figure 5. Qualitative Data Analysis Process, Ulin et al, 2005.

Reading Coding

Questioning Interpreting Verifying

Reducing Displaying

The themes within the theoretical framework that correspond to the research questions served as the a priori codes (e.g. barriers, facilitators, constraints, etc.). This approach to “prefigured” coding is popular in the health sciences and the PI remained open to coding themes that emerged during the analysis (Crabtree & Miller, 1992;

Creswell & Creswell, 2007). A codebook was generated and included the definitions of a priori codes and emerging codes to facilitate coding consistency and clarity (Appendix J).

The coding scheme remained flexible and evolved over time as new themes emerge. All interview transcript coding was conducted using QSR NVivo 10 software on a continuous basis. Line-by-line coding facilitated more complex features available through NVivo 10 such as coding queries by unit of analysis, level of involvement, and mission year.

Once all documents were coded, the data was displayed by thematic area using the prescribed codes. Subthemes were generated and led to the development of

hypothesis about the themes. Comparison of themes within and between each unit of analysis led to the development of theoretical explanations that assisted in validating previous and emerging conclusions (Ulin et al., 2005). After the data was displayed, data reduction commenced. Data reduction is the systematic method of extracting the more essential concepts and relationships in the data (Ulin et al., 2005). Primary and secondary themes were prioritized and non-essential information excluded from further interpretation. The final step of data interpretation included the determination of relationships and patters as well as more focused explanations of the data’s essential meaning (Miles & Huberman, 1994). During this step, the PI ensured the meaning extracted from the study participants had relevance to a larger population and answered the original research questions based on the theoretical framework (Ulin et al., 2005).

Documentary Materials Review

The collection and review of documentary materials is a technique used by researchers to gain a better understanding of the events that one was unable to witness

(Stake, 1995). In this study, planning documents used to shape the PP08 and PP10 mission directly and indirectly were requested upon conclusion of the key stakeholder interviews. The documents provided historical context and insight into the culture of each participating organization. Understanding both context and culture provided a better understanding of the possible advantages and disadvantages of the partnership, facilitators and barriers to joining the partnership, and external and internal constraints to the partnership. Furthermore, the information gathered during the review of documentary

materials helped substantiate data from the key stakeholder interviews. Table 5 highlights the documentary materials collected and reviewed.

Table 5. Documentary Review Material

Level Document

Policy • DoD Directive 5100.46 Foreign Disaster Relief (FDR) (2012) • DoD Instruction 6000.16 Military Health Support to Stability Operations (2010) • DoD Instruction 3000.05 Stability Operations (2009) • DoD Instruction 2205.02 Humanitarian and Civic Assistance (HCA) Activities (2008) • National Security Presidential Directive-44 (NSPD-44) on Management of Interagency Efforts Concerning Reconstruction and Stabilization (2005) Guidance • Sustaining U.S. Global Leadership: Priorities for 21st Century Defense (2012) • National Military Strategy of the United States of America: Redefining America's Military Leadership (2011) • Joint Publication 3-08: Interorganizational Coordination During Joint Operations (2011) • DoD Quadrennial Defense Review (2010) • U.S. National Security Strategy (2010) • Joint Publication 3-29: Foreign Humanitarian Assistance (2009) • OPNAV Instruction 5440.75B Administration, Operation, and Logistic Support of T-AH 19 Mercy Class Hospital Ships (2010) • U.S. Pacific Command Strategic Guidance (2012) • DoS Quadrennial Diplomacy and Development Review, Leading Through Civilian Power (2010) • U.S. Assistance to Timor-Leste: Promoting Stability, Partnering or Progress (2009) • Timor-Leste Strategic Development Plan 2011-2030 (2011) • Strengthen Communities in the area of Health Through SISCa (Integrated Community Health Services) Implementation Guide Planning/Execution • Pacific Partnership 2010 Timor-Leste CONOPS Brief (Unclassified) • U.S. DoD Pacific Partnership 2010 Post Deployment Brief (Unclassified) • Pacific Partnership 2010 Timor-Leste Nularan Primary School ENCAP – NMCB Eleven After Action Report Jul-Sep 2010 • USNS Mercy (T-AH 10) and Pacific Partnership May-September 2008 Post Deployment Brief (Unclassified) • Pacific Partnership 2008 Post Deployment Brief, Briefing to Commander, U.S. THIRD Fleet (Unclassified)

Study Limitations

Validity

When judging the overall quality of research designs, many perspectives exist in the scientific community. In the qualitative research, Lincoln and Guba use terms such as credibility, authenticity, transferability, dependability and confirmability to establish what they describe as the trustworthiness of a study (Lincoln & Guba, 1985). Others such as Yin recommend using four tests common to all social science methods, which include construct validity, internal validity, external validity, and reliability (Yin, 2009).

These constructs are commonly used in quantitative studies and can be applied to qualitative research.

Internal validity is defined as the extent to which research study findings accurately represent the causal relationship between the intervention and outcome of interest (National Institues of Health, 2008). Internal validity can be challenged in case studies when an investigator does not directly observe an event and makes inferences of causality based on interview and documentary analysis (Yin, 2009). One approach used in qualitative research to control for internal validity is to identify a specific unit of analysis and theoretical framework prior to data collection. This study identified both, which allowed the PI to test the internal validity of the theory during the data analysis process. Furthermore, by using multiple sources of evidence in data collection such as interviews and documentary materials, convergent lines of inquiry were explored thereby increasing the internal validity of the findings with reality (Yin, 2009).

External validity deals with the generalizability of the study findings beyond the immediate case study (Yin, 2009). According to Yin, the investigator strives to

generalize the case study results to a broader theory which would be the partnership theory that was validated through this study (Yin, 2009). The partnership theory could be applied to other contexts beyond hospital ship missions where the USG partners with foreign nations, host nations, and NGOs to support health and public diplomacy efforts.

Additionally, using multiple units of analysis that were consistent among other countries visited by the USNS Mercy during the 2008 and 2010 Pacific Partnership missions, the results of this case study should be generalizable to other cases (countries) and other

Pacific Partnership missions.

Reliability

Reliability in qualitative research can be defined as the likelihood that a similar study would elicit similar themes and findings (Green & Thorogood, 2009). Given the nature of qualitative research, obtaining identical results in a similar study would be unlikely (Ulin et al., 2005). This may be further compounded by the position or role of the researcher. Although the PI for this study is an active duty military officer, the role as a doctoral candidate conducting dissertation research was used among the four units of analysis. All interviews were conducted by the PI in business attire and with military stakeholders that did not have a chain-of-command relationship with the interviewer.

This neutral role mitigated the undue influence military rank could have between the interviewer and interviewee and increased the likelihood that a similar academic study would produce similar results.

Additionally, to increase reliability in qualitative studies, researchers use and document a consistent research process (Yin, 2009). Reliability was achieved in this

study by using a published case study protocol and maintaining a case study database.

The case study protocol outlined in the methods section included an IRB approved interview guide based on the a priori theoretical framework, conducting specific field procedures such as presentation of credentials through IRB approved telephone/email introduction scripts as well as the language used to protect human rights in the IRB approved informed consent form further increased the reliability of the research findings.

The overarching embedded case study questions were clearly outlined in the methods section and detailed individual questions in the IRB approved interview guide. Providing this level of detail in the protocol increases the replicability for future studies and increase the reliability of the findings. Maintaining the raw data obtained from the semi- structured key stakeholder interviews in a case study database using QSR NVivo 10 also increases the reliability of this case study (Yin, 2009). Through the use of audio recordings and transcription, verbal elements of the key stakeholder interviews were captured in full. The PI was the only individual coding the transcripts thereby eliminating the possibility of divergent coding between multiple coders (Creswell &

Creswell, 2007).

Selective Deposit Bias

Leveraging grey literature and peer reviewed journals to inform the study background and aid in developing an impact framework may result in bias through selective deposit. This occurs when information gaps exist due to selective event recordings in the peer reviewed and grey literature (Green & Thorogood, 2009). To mitigate this potential bias, emerging partnership themes captured during the interview

process outside of the theoretical framework were noted. Furthermore, interviewing representatives from multiple units of analysis serving at different levels mitigated bias and provided a comprehensive array of viewpoints.

Selection Bias

The potential for interviewee selection bias also exists. Requesting individuals from each organization with the largest amount of involvement in the PP08 and PP10 mission mitigated this effect. Balanced representation across all units of analysis from the policy, operational, and implementation levels was achieved.

Recall Bias

Probes were used during the key stakeholder interviews to stimulate recollection of events from the Mercy mission to Timor-Leste in 2008 and 2010. Individuals with negative experiences of the hospital ship mission may have been more apt at recalling events from memory than individuals with either neutral or positive experiences.

Following-up the semi-structured questions with specific probes when there was a lapse in recollection triggered a response and ensured the study findings were representative of all participant experiences.

Generalizability

Incorporating participants from the diverse range of partners representing different levels of involvement increased the generalizability of the findings between each unit of analysis and among the different countries visited by the Mercy during the

missions. However, Timor-Leste is a unique case that was visited on four occasions by the Mercy since 2004 and this historical context may limit the generalizability of the findings to countries with a similar number of missions. Without testing the partnership theory against USNS Comfort Continuing Promise missions in Latin American and the

Caribbean, the results will not be generalizable to all U.S. DoD hospital ships.

Other Considerations

This research, to include travel to Timor-Leste, was made possible by a $10,000

U.S. Pacific Command and a $3,000 U.S. Army Medical Department Center and School grant. The funds supported two weeks in Dili, Timor-Leste to conduct key stakeholder interviews. Based on limited funding, as well as the 3-year timeframe to complete the

DrPH degree in accordance with the U.S. Army Long Term Health Education Program,

37 key stakeholder interviews were conducted and transcribed. Although more interviews conducted across both PP missions with the support of a research team would have been ideal to ensure every aspect of the research questions were covered within and between the units of analysis, the time and resource constraint dictated the need to conduct a realistic number to meet the research objectives. Finally, this study does not include host nation recipients as key stakeholders of the partnership. Although they are the beneficiaries of the humanitarian assistance rendered through the hospital ship mission partnership, the DoD does not consider the population as a key partner of the PP mission.

Protection of Human Rights

Ethical clearance was obtained from The George Washington University and

Medical Center Office of Human Research using the Exempt From Institutional Review

Board Review Request Form (Appendix K). Based on published guidance from the

Office of Human Research and in accordance with the Code of Federal Regulations Title

45 (Public Welfare Department of Health and Human Services), Part 46 (Protection of

Human Subjects), Section 46.102 (Definitions), this study involves minimal risk to subjects and fit into an exempt review category of research (George Washington

University Institutional Review Board, 2011). Formal ethics approval from the Timor-

Leste Ministry of Health was granted and memorandum for record obtained following an initial study protocol presentation to the Cabinet of Health Research and Development

(Appendix F).

Each study participant read the informed consent form before starting the interview (Appendix E and G). Participants were notified the information they provided would be treated with confidentiality. They were notified of their right to refuse to answer any of the questions and to stop their participation in the study at any time. Each participant was given the opportunity to ask questions and provided a copy of the informed consent form before starting the interview. The informed consent form included the PI and GWU Office of Human Research contact information if questions arose after the study.

If the results of this study are presented at scientific meetings or published in scientific journals, no information will be included that could identify the individual or their answers personally. Audio files, written notes, and a hard copy of participant

contact information will remain in the custody of the PI in a locked box and destroyed one year after the study is complete to further protect participant confidentiality. The lock box will be in the possession of the PI and the key will be kept in a separate location.

Electronic transcripts were transferred into QSR NVivo 10 software on a password protected personal computer belonging to and accessibly only by the study PI. An electronic copy of participant contact information was also maintained on the same password protected personal computer and will be destroyed one year after the study is complete to further protect participant confidentiality.

Summary

The research methods used in this study increased the understanding of how and why hospital ship missions influence partnerships. The systematic literature review illustrates how the DoD and participating organizations, and the broader international community, characterize and evaluate hospital ship missions. Gaps in knowledge identified during the systematic review were used to inform the embedded case study focusing on the USNS Mercy mission to Timor-Leste in 2008 and 2010. The embedded case study across two time periods increased the validity and generalizability of the findings. Key stakeholder interviews of individuals representing each unit of analysis across both missions explored the experiences of each participant and provided rich information. The documentary review of policy, guidance, and planning/execution documents related to the case study missions’ substantiated data collected during the key stakeholder interviews. Triangulation of data collected through the systematic literature review, key stakeholder interviews, and the documentary review assisted in validating the

partnership theoretical framework and increasing our understanding of the partnership impact of hospital ship missions.

Chapter 4. Results

Overview

Part one of this dissertation used a systematic literature review and found of the

1445 sources reviewed, a total of 43 publications met inclusion criteria for review. Six

(13.9%) met empirical documentation criteria and 37 (86.0%) were considered non- empirical expert opinions and anecdotal accounts that were primarily descriptive in nature. Overall, disaster response accounted for 67.4% (29/43) and humanitarian assistance 25.6% (11/43) of sources. Public and private sector participants produced

79.0% (34/43) and 20.9% (9/43) of the publications respectively. Of private sector publications, 88.9% (8/9) focused on disaster response compared to 61.8% (21/34) from the public sector. Of all publications meeting inclusion criteria, 81.4% (35/43) focused on medical care, 9.3% (4/43) discussed partnerships, 4.7% (2/43) training, and 4.7%

(2/43) medical ethics and strategic utilization. No primary author publications from the diplomatic, development, or participating host nations were identified. One (2.3%) of the

43 publications was from a partner nation participant.

Part two of this dissertation used an embedded case study of Timor-Leste across two missions and time periods, Pacific Partnership 2008 and 2010. The embedded case study was used to expand the knowledge related to hospital ship partnerships and answer the research questions: how and why do hospital ship missions influence partnerships among participants, what are the perceived advantages and disadvantages of partnering with the hospital ship, what were the facilitators and barriers to the partnership, and how did organizations change as a result of the partnership. Thirty-seven key stakeholders representing the four units of analysis [USG 38% (14/37), PN 19% (7/37), HN 16% 69

(6/37), and NGOs 27% (10/37)] and three different levels of involvement [strategic 32%

(12/37), operational 38% (14/37), and tactical 20% (11/37)] were interviewed. Thirty- two percent (12/37) of the key stakeholders participated in both PP08 and PP10, 16% percent (6/37) took part in only PP08, and 43% (16/27) only PP10.

Fifteen themes related to how and why hospital ship missions influence partnerships emerged during the data analysis of 469 pages of interview text and included the following: opening dialogue, developing trust, developing relationships, developing credibility, understanding partner constraints, understanding partner agenda, understanding HN needs, developing new perspectives, sharing resources, generating innovation, achieving parent organization objectives, increasing visibility, increasing HN capacity, sharing leadership, and performing new activities.

Factors that facilitated joining the mission included partner nations seeking a regional presence, historical relationships between senior executives of participating organizations, and word of mouth between organizations. Enablers of the partnership included historical relationships, host nation receptivity, continuity of personnel, and integration among partners. The primary factor identified as a barrier to joining the hospital ship mission was the U.S. military leading the hospital ship mission. Internal constraints to the partnership included the short mission duration, resentment among participants, and a lack of personnel continuity. External constraints included low host nation and USAID capacity.

A review of documentary materials provided by the study participants yielded an additional source of evidence that supported the key stakeholder interview findings and proposed theoretical framework. A total of 22 documents were reviewed which included

5 policy, 12 guidance, and 5 planning/execution references. The documents reinforced the 15 themes related to how hospital ship missions influence partnerships.

Research Question 1: How are U.S. Navy

hospital ship missions evaluated in the literature?

Descriptive Statistics

Part One of this study used a systematic literature review to answer how hospital ship missions are evaluated in the literature. The number of sources identified and search term strategies used for each of the eight databases are outlined in Appendix L. An average of 181 sources per database were found with PubMed yielding the highest at 569 and CENTRAL the lowest at 3. A total of 1445 sources were identified and 1308 remained after excluding exact duplicate matches using the software program RefWorks

(Figure 6). Additional duplicates that were not an exact text match were excluded during the screening process. After screening source titles and abstracts, 1246 sources did not meet the inclusion criteria. The remaining 62 sources were reviewed in full and 19 did not meet the inclusion criteria and were excluded (Appendix M). A total of 43 sources met the inclusion criteria and were coded (Appendix N).

Figure 6. Systematic Literature Review Findings

Of the 43 sources, 23 (53.5%) were published in military journals and 20 (46.5%) in health journals. Only one (2.3%) originated f rom outside the United States (T able 6).

All sources meeting the inclusion criteria were from published journals although one emanated from dissertation research. The dissertation was excluded during the screening process as a duplicate to the 2009 journal article. Primary aut hors from the public sector made up 79.0% (34/43) of sources while the private sector made up 20.9% (9/43). Thirty

(69.8%) originated from the military, nine (20.9%) from the health, and four (9.3%) from the not for profit sectors.

Disaster response missions accounted for 29 (67.4%) of the publications.

Humanitarian assistance made up another 11 (25.6%) and both missions were discussed in three (7.0%) of the publications. The actual missions described varied with Operation

Unified Assistance (Asian tsunami relief) cited most often in 17 (39.5%) of the publications. Operation Unified Response (Haiti earthquake relief), Pacific Partnership,

Continuing Promise and “all” missions made up 12 (27.9%), eight (18.6%), two (4.7%) and four (9.3%) respectively. Overwhelmingly, 35 (81.4%) of the publications focused on medical care, four (9.3%) mentioned partnerships or collaborations, two (4.7%) exercises or training, and two (4.7%) ethics and strategic utilization.

Of all sources meeting the inclusion criteria, 37 (86.1%) were non-empirical.

Among these, descriptive accounts of individual experiences made up 31 (72.1%) of the publications and an additional 6 (14.0%) were editorials or letters to the editor. Only five

(11.6%) of the total sources included in the study used quantitative analysis and one

(2.3%) qualitative analysis. Of the six empirical publications, five (83.3%) were non- experimental quantitative and one (16.7%) grounded theory qualitative. One additional study “offered an illustrative case” and was coded as a qualitative case study although the study design was not explicitly identified. Overall, the results suggest a significant gap in empirical studies.

Table 6. Systematic Literature Review Descriptive Statistics

Variable n (%) Variable n (%)

Country of Origin Actual Mission US 42 (97.7) Continuing Promise/Partnership for the Americas 2 (4.7) Non-US 1 (2.3) Pacific Partnership 8 (18.6) Type of Publication Operation Unified Assistance (Tsunami Relief) 17 (39.5) Journal 43 (100) Operation Unified Response (Earthquake Relief) 12 (27.9) Book 0 (0) Katrina Response 0 (0) Book Chapter 0 (0) All 4 (9.3) Dissertation/Thesis 0 (0) Primary Focus Area Conference Proceedings 0 (0) Exercise/training 2 (4.7) Other 0 (0) Medical Care 35 (81.4) First Author Affiliation Dental Care 0 (0) Public 34 (79.0) Veterinary Care 0 (0) Private 9 (20.9) Partnership/Collaboration 4 (9.3) Sector Other 2 (4.7) Health 9 (20.9) Research Methodology Military 30 (69.8) Quantitative 5 (11.6) Diplomacy 0 (0) Qualitative 1 (2.3) Development 0 (0) Mixed Methods 0 (0) Profit 0 (0) Descriptive 31 (72.1) Not for Profit 4 (9.3) Other 6 (14.0) Mission Type Detailed Methodology Humanitarian Assistance 11 (25.6) Experimental 0 (0) Disaster Response 29 (67.4) Non-experimental 5 (11.6) Both 3 (7.0) Quasi-experimental 0 (0) Narrative 0 (0) Phenomenology 0 (0) Grounded Theory 1 (2.3) Ethnography 0 (0) Case Study 1 (2.3) Other 36 (83.7)

Bivariate Analysis

Author affiliation by Mission Type

When considering who is documenting what, 21 (61.8%) of the public sector sources meeting the inclusion criteria focused on disaster response (Table 7). Ten

(29.4%) focused on humanitarian assistance. The private sector had a greater affinity for documenting disaster response missions. Eight (88.9%) focused on disaster response while one (11.1%) focused on humanitarian assistance. Among private sector publications, six (66.7%) focused on Operation Unified Assistance, two (22.2%) on

Operation Unified Response, and one (11.1%) on Pacific Partnership.

Sector by Mission Type

First authors representing the health, military, and not-for-profit sectors overwhelmingly published on disaster response. Nine (100%) publications by health sector authors focused on disaster response, three (75.0%) from the not-for-profit sector, and 17 (56.7%) from the military sector. None of the health sector publications focused on humanitarian assistance missions and only three (33.3%) from the military and one

(25.0%) from the not-for-profit sectors. No publications from the diplomatic, development, or profit sectors were identified in the systematic review.

Primary Focus Area by Mission Type

Twenty-three (65.6%) publications focusing on medical care, two (100%) exercises/training, and three (75%) partnerships/collaboration fell into the disaster response domain. The disaster response medical care publications were evenly split

between Operations Unified Assistance and Unified Response (12/23 [52.2%] vs. 11/23

[47.8%]). The remaining medical care publications focusing on humanitarian assistance missions disproportionately related to Pacific Partnership compared to Continuing

Promise (7/9 [77.8%] vs. 2/9 [22.2]). Three (75%) publications focusing on partnerships described Operation Unified Assistance while one (25%) described Pacific Partnership.

No publications related to dental or veterinarian care were identified.

Research Method by Mission Type

When considering research methodology, only five (11.6%) sources meeting the inclusion criteria used quantitative analysis. Of these, three (60%) were related to disaster response while two (40%) were split between humanitarian assistance and “both” domains. The only qualitative study fit the disaster response domain and the Operation

Unified Assistance mission.

Detailed Research Methodology by Mission Type

A more detailed analysis of research methodology finds all five of the quantitative publications were non-experimental. Three (60%) focused on disaster response while two (40%) focused on humanitarian assistance and “both” domains. The qualitative grounded theory and case study focused on disaster response and related to Operation

Unified Assistance. Thirty-one (72.1%) publications simply described individual experiences of which 24 (74.2%) focused on disaster response. No experimental or quasi-experimental quantitative studies nor narrative, phenomenology, or ethnographic qualitative studies were identified.

Table 7. Systematic Literature Review Bivariate Analysis

Specific Hospital Ship Mission General Mission Type Total Continuing Pacific Operation Unified Operation Unified All HA DR Both Promise Partnership Assistance Response Missions Author Affiliation Public 34 2 (5.9) 7 (20.6) 11 (32.4) 10 (29.4) 4 (11.8) 10 (29.4) 21 (61.8) 3 (8.8) Private 9 0 (0) 1 (11.1) 6 (66.7) 2 (22.2) 0 (0) 1 (11.1) 8 (88.9) 0 (0) Sector Health (nonmilitary) 9 0 (0) 0 (0) 7 (77.8) 2 (22.2) 0 (0) 0 (0) 9 (100) 0 (0) Military 30 2 (6.7) 7 (23.3) 8 (26.7) 9 (30) 4 (13.3) 10 (33.3) 17 (56.7) 3 (10) Diplomacy 0 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Development 0 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Profit 0 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Not for Profit 4 0 (0) 1 (25) 2 (50) 1 (25) 0 (0) 1 (25) 3 (75) 0 (0) Primary Focus Area Exercise/training 2 0 (0) 0 (0) 2 (100) 0 (0) 0 (0) 0 (0) 2 (100) 0 (0) Medical Care 35 2 (5.7) 7 (20) 12 (34.3) 11 (31.4) 3 (8.6) 10 (28.6) 23 (65.7) 2 (5.7) Dental Care 0 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Veterinary Care 0 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Partnership 4 0 (0) 1 (25) 3 (75) 0 (0) 0 (0) 1 (25) 3 (75) 0 (0) Other 2 0 (0) 0 (0) 0 (0) 1 (50) 1 (50) 0 (0) 1 (50) 1 (50) Research Methodology Quantitative 5 1 (20) 0 (0) 1 (20) 2 (40) 1 (20) 1 (20) 3 (60) 1 (20) Qualitative 1 0 (0) 0 (0) 1 (100) 0 (0) 0 (0) 0 (0) 1 (100) 0 (0) Mixed Methods 0 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Descriptive 31 1 (3.2) 6 (19.4) 15(48.3) 8 (25.8) 1 (3.2) 8 (25.8) 23 (74.2) 0 (0) Other 6 0 (0) 2 (33.3) 0 (0) 2 (33.3) 2 (33.3) 2 (33.3) 2 (33.3) 2 (33.3)

Specific Hospital Ship Mission General Mission Type

Total Continuing Pacific Operation Unified Operation Unified All HA DR Both

Promise Partnership Assistance Response Missions Detailed Methodology Experimental 0 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Non-experimental 5 1 (20) 0 (0) 1 (20) 2 (40) 1 (20) 1 (20) 3 (60) 1 (20) Quasi-experimental 0 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Narrative 0 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Phenomenology 0 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Grounded Theory 1 0 (0) 0 (0) 1 (100) 0 (0) 0 (0) 0 (0) 1 (100) 0 (0) Ethnography 0 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Case Study 1 0 (0) 0 (0) 1 (100) 0 (0) 0 (0) 0 (0) 1 (100) 0 (0) Other 36 1 (2.8) 8 (22.2) 14 (38.9) 10 (27.8) 3 (8.3) 10 (27.8) 24 (66.7) 2 (5.6)

Research Question 2: “How” and “why” do U.S. Navy hospital ship missions

influence partnerships among the U.S. government, host nations, partner nations,

and

non-governmental organizations?

Stakeholder Descriptive Statistics

Part two of this research study used an embedded case study across two time periods to answer this research question. The key stakeholders for the case study included 37 individuals representing the U.S. Government, Timor-Leste Government,

Partner Nation Militaries, and NGOs (Table 8). An average number of 9.3 participants per organization were interviewed with the highest number of participants from the U.S.

Government (n=14) while Timor-Leste Government had the lowest number of participants (n=6). The average age of the stakeholders was 46 with the youngest participant being 28 years of age representing the partner nation militaries and the oldest being 69 years of age representing the NGOs. Thirty-five percent (13/37) of the stakeholders were female.

The stakeholders had an average of 10 years experience conducting humanitarian assistance related work with partner nation military participants having the least (2 years) and NGOs the most (15 years). Thirty-eight percent (14/37) of participants had prior experience working on Navy hospital ship missions with the lowest reported by partner nation participants (14%) and the highest by Timor-Leste Government participants

(67%). These results are not surprising since the Mercy visited Timor-Leste on four different missions. Exactly half of the U.S. Government, Timor-Leste Government, and

NGO participants reported prior experience working with U.S. Government interagency partners. This too is not surprising since USAID is a key interagency partner within the

USG and works with NGOs to implement development programs in foreign nations such as Timor-Leste. None of the partner nation military participants reported similar interagency experience. Forty-one percent (15/37) of the stakeholders reported prior experience working with other military partner nations with the partner nation military participants reporting the highest level at 57% (4/7) and host nation participants the lowest at 33% (2/6). This finding reinforces the historical willingness of militaries to collaborate and the more recent evolution of military-to-civilian collaboration. Almost two-thirds (23/37) of participants reported prior experience working with NGOs. Timor-

Leste Government officials reported the highest level of NGO working experience at

83% (5/6) with partner nation military participants the lowest at 29% (2/7). The high percentage among host nation participants is expected based on the large role NGOs played in supporting the recent post-conflict nation. The low percentage among partner nation military participants might suggest cultural differences between the units of analysis.

In terms of Pacific Partnership hospital ship missions, 32% (12/37) of the stakeholders participated in both PP08 and PP10. Sixteen percent (6/37) took part in only

PP08 and 43% (16/27) only PP10. Overall, a similar number of participants representing the strategic, operational, and tactical levels of involvement were interviewed. Strategic participants made up 32% (12/37) of the stakeholders, while 38% (14/37) worked at the operational and 30% (11/37) at the tactical levels. Strategic level participant varied across units of analysis with Timor-Leste Government officials having the highest at 67%

(4/6) and NGOs the lowest at 10% (1/10). Operational level involvement was highest among U.S. Government participants at 50% (7/14) and lowest among partner nation military participants at 14% (1/7). And tactical level involvement was highest among partner nation military participants at 71% (5/7) with none (0/6) of the Timor-Leste

Government participants working at this level during the hospital ship missions.

Table 8. Key Stakeholder Descriptive Statistics

Demographics U.S. Partner Host Non- Total Government Nation Nation governmental Military Organization Number of study 38% (14/37) 19% (7/37) 16% (6/37) 27% (10/37) 37 participants Mean age in years 47 (32-63) 43 (28-55) 42 (46-45) 50 (29-69) 46 (28-69) (range) Sex (female/male) 21% / 79% 43% / 57% 50% / 50% 40% / 60% 35% / 65%

Mean years of 10 (0-37) 2 (0-6) 12 (2-17) 15 (0-40) 10 (0-40) humanitarian assistance related work (range) Prior experience 29% (4/14) 14% (1/7) 67% (4/6) 50% (5/10) 38% (14/37) working on a hospital ship mission Prior experience 50% (7/14) 0% (0/7) 50% (3/6) 50% (5/10) 41% (15/37) working with interagency partners Prior experience 36% (5/14) 57% (4/7) 33% (2/6) 40% (4/10) 41% (15/37) working with other military partner nations Prior experience 64% (9/14) 29% (2/7) 83% (5/6) 70% (7/10) 62% (23/37) working with NGOs Only Pacific 14% (2/14) 57% (4/7) 0% (0/6) 0% (0/10) 16% (6/37) Partnership 2008 Only Pacific 36% (5/14) 14% (1/7) 67% (4/6) 60% (6/10) 43% (16/37) Partnership 2010 Both Pacific 29% (4/14) 29% (2/7) 33% (2/4) 40% (4/10) 32% (12/37) Partnership 2008 & 2010 Only Pacific 21% (3/14) 0% (0/7) 0% (0/6) 0% (0/10) 8% (3/37) Partnership 2011 Strategic (Policy) 43% (6/14) 14% (1/7) 67% (4/6) 10% (1/10) 32% (12/37) Level Involvement Operational (Planning) 50% (7/14) 14% (1/7) 33% (2/6) 40% (4/10) 38% (14/37) Level Involvement Tactical (Execution) 7% (1/14) 71% (5/7) 0% (0/6) 50% (5/10) 30% (11/37) Level Involvement

Perceived Mission Goal

Knowing the goals of the hospital ship mission as described by the participating organizations increases our understanding of their perceptions and expectations. Through this knowledge, a better understanding of how these perceptions and expectations affect whether participants determined the mission impacted their partnership between units of analysis is achieved. As described in Chapter 2, the secondary mission of the Navy hospital ship is to provide humanitarian assistance. The U.S. Pacific Command exercises this task through the biennial Pacific Partnership mission. One of the stated goals of the

Pacific Partnership mission is to build regional partnerships. The results of this study suggest the units of analysis perceived the goals of the mission and the ability to achieve them differently (Table 9). U.S. Government and NGO participants identified building partnerships, providing a training opportunity, and rendering humanitarian assistance as the three goals of the mission. Opinions were mixed as to whether the goals were achieved. Partner nation participants mentioned partnerships and rendering humanitarian assistance as the two goals with predominantly positive opinions of achievement. The host nation participants identified rendering humanitarian assistance as the only goal and all stated it was achieved. A brief description by unit of analysis is below and a detailed account is found in Appendix O.

Table 9. Perceived Mission Goal Within and Between Units of Analysis

Theme USG PN HN NGO Between Units of Analysis

Tactical Operational Strategic

Building Partnerships X X X X X

Training Opportunity X X X X X

Rendering Humanitarian X X X X X X X Assistance

U.S. Government (Military and non-military participants)

The three main goals described by USG participants included a foreign policy effort to build relationships; a humanitarian and disaster response training component; and the delivery of humanitarian assistance and medical services. In the context of foreign policy and relationships, participants stated “the larger picture, obviously, is part of the whole Theater Security Cooperation for PACOM and from PACFLT that we want to go ahead and establish long-term relationships in the area.” A strategic level participant said, “a huge part of the mission is just when we put hundreds of American and partner nation people through the country, it just builds a lot of goodwill and support among the population when they see us, you know, MEDCAPs, showing compassion, empathy, and things like that.” In a training context, the goal was described as, “to increase everybody’s ability to respond to disasters because each one of these countries has disasters. The partners who send people to our ship, they have disasters. We have disasters. So getting an appreciation of how disaster response can work and how you can partner with NGOs is really important.” In the context of service delivery, the goal was described as “to address the need that is beyond the capacity of the country.” This included, “the delivery of humanitarian services, medical services, but then also the development of, or strengthening of the working relationship that existed between our two militaries.” Another participant described service delivery as a lower level goal by stating, “delivering humanitarian assistance and medical services, but my understanding all along was that was definitely a tertiary goal.”

In terms of the partnership achieving the goals, opinions were mixed. Overall,

USAID participants were not as positive as DoS and DoD personnel. One participant

said at a “very high level it didn’t seem to have too much change there.” A DoD operational level participant with experience on multiple missions said, “for healthcare you have to come back multiple times over a few years working on the same project to really build capacity where you develop people, as you know, and in medical education it takes years of training and we go in and we have this idea that in just a two week visit we’re going to build capacity. That’s really a hard thing to demonstrate.” They went on to say, “I think PACFLT, the line side, is looking for these big, gigantic gains from these two-week missions and I don’t think we’re ever going to see that.” Other participants stated the goals were achieved. A DoS strategic level participant stated “Profoundly. I think out of my three years of service in Timor-Leste the greatest display of U.S. commitment to Timor-Leste was manifested through the visit of the Mercy…Just the impact that we had on showing the flag and showing that Americans cared to the average citizen of Timor-Leste, including in some very remote areas of the country, was exceptional, it exceeded my expectations.” Another said, “I would have to say very successful, just simply looking at the numbers of treatments that they can’t get on the island and just the shear volume of people that were treated.”

Partner Nation Military (Pacific Region and non-region presence)

Two main goals similar to those described by the U.S. Government participants emerged from partner nation military participants. They included building relationships/partnerships and the delivery of humanitarian assistance/medical services.

In terms of relationships and partnerships, partner nation military participants stated the goal was “to learn about how other countries worked.” One participant described the

goal as being composed of multiple elements that included, “to enhance the partnership in that region…the provision of humanitarian type assistance…to build capacity within host nations that they did not have and to meet ongoing global engagement strategies, and to enhance security in the region.” In the context of service delivery, participants described the goal as “to work together to provide as much treatment or care, services to the locals as we could.” Some participants could not recall the mission goals and stated,

“Truthfully, I can’t remember.”

In terms of the partnership achieving the goals described by each partner nation military participant, opinions were predominantly positive. Two responded, “I think they were very successful.” Related to service delivery and partnership, one participant stated

“I think that the surgeons, dentists, ophthalmology, the physios did a splendid job and could see their results.” Another, “We got to spend a lot of time with them and yeah, so it was a good partnership between us all because obviously we have the same goal in providing that care and treatment for the locals.” However, another participant was skeptical in terms of the service delivery goal and stated, “These hospital ships could anchor and be there for a couple of years and still not see everybody, do everything.”

Host Nation

Among host nation participants, one main goal of the hospital ship missions emerged. This goal focused exclusively on delivery of humanitarian assistance and medical services to the local population. One participant stated, “The main purpose is to provide the assistance to the people.” Another stated, “I think the most important goal is

to actually help contribute to service delivery in Timor-Leste…filling some of the gaps that the government experience in Timor-Leste.” One participant further described service delivery by saying, “the objective of the partnership to complement the government service because we know Timor-Leste is a new country.” A second goal was described by one participant and related to training or capacity building. They said, “In

2010 for the mission, there’s just not one focus on humanitarian service or healthcare, also they provide training to our national people, that’s important.”

In terms of the partnership achieving the goals described by each host nation participant, opinions were positive. Responses included “I think it’s successful” to a very assertive “for sure they achieved it.”

Non-Governmental Organization (long-term, short-term PP relationship, local NGOs)

Three main goals similar to U.S. Government participants, although slightly different in tone and context, emerged among NGOs. These included a foreign policy effort to build relationships, a humanitarian and disaster response training component, and the delivery of humanitarian assistance and medical services. Variability in responses existed by level of participation (strategic, operational, tactical). Strategic level participants typically captured all three of the perceived goals in their response while tactical level participants primarily responded to the delivery of services.

In the context of foreign policy and relationship building, participants stated the goal was “to increase better relationships with the countries we visited and give a picture of the United States of America as not being the big evil giant.” Others described the foreign policy goal in more blunt terms. “I think it’s PR. I think it’s the soft diplomacy

type of things.” Linked to relationships, one participant stated, “the goal I was told that we would be performing was building relationships and also, so if there was a natural disaster or a concern that country had a natural disaster or a problem in the country, then they would have better relationships with the U.S. and obviously non-government organizations so that we could help them better in the future.” One respondent builds on the notion of the training goal by adding partnership and service delivery by saying, “if you look at really kind of when the DOD presents these and they’re very honest about it, it says, these are training missions, number one. I think the partnerships and the kind of inter-operability training and that sort of thing is there with that or maybe even second and farther down the line, and, it’s like I said, it’s clearly stated but I think somewhat farther down the line is that help support the beneficiaries, which tends to be a little bit lower down the chain, and for volunteers that don’t understand the concepts of the medical diplomacy and the relationship building and that sort of thing, when they’re there just to help sometimes you got to really manage that expectation.” Another participant mentions partnership and training goals while describing constraints in meeting service delivery - “the stated goal is to strengthen regional alliances, build capabilities, to respond to crisis basically…there’s also humanitarian objectives which is to improve the health of these people and these populations, but to tell you the truth, I mean, it’s like spitting in the ocean.” Others describe the goal of service delivery by stating, “the mission to support the government, support the Ministry of Health, to fill the gap, and to ensure that better health for the Timorese nation.”

Similar to U.S. Government participants, opinions were mixed in terms of the partnership achieving the goals described by each NGO participant. Some participants

were unsure and stated, “No idea to be honest because I think that’s probably more a diplomatic and political” and “if you’re looking for objective measures, I’m not sure, I don’t know if I could come up with any.” Other participants were negative in their opinions and stated, “I think the international public health outcomes are probably very, very limited.” Another stated, “There’s always conversation that we’re, it’s a partnership and we’re partners but, in the play-out it’s not really been the case.” Some participants responded with mixed opinions by stating, “I think it was very, pretty effective. It was definitely good door-opening. We saw tons of patients, did lots of surgeries, handed out lots of pharmaceuticals, pulled lots of teeth, issued lots of eyeglasses, but did it improve the, by any U.N., WHO, World Health, U.S. public health standards of measurement and effectiveness, did we improve the health? Nobody can say and numbers of patients seen has no correlation to improving the health. The fact is we only treated acute presentations, didn’t treat any chronic disease.” Yet others had positive opinions and stated, “I think the training aspects do go very well and I think the inter-operability, the partnership development within the United States, i.e., the DOD, interagency, NGOs, the folks that are deploying abroad, I think that interface goes very well.”

Partnership Definition

With a better understanding of how each unit of analysis defines the hospital ship mission goals, which included partnership, there was a need to understand how different participants define “partnership.” Two additional questions were asked during the open- ended key stakeholder interviews and included defining partnership in their own terms and the ability of the hospital ship partnership to achieve their stated definition. How

each participating organization defines “partnership” and perceives achieving this definition also impacts “why” the hospital ship missions influence partnerships. The results suggest the units of analysis define partnership differently with various levels of achieving their definition (Table 10). An overarching theme of “two separate entities working towards a mutual goal” was prevalent among U.S. Government participants with opinions mixed in terms of the mission achieving this definition. Many partner nation military participants used the term equity to define partnership and they too expressed mixed opinions of the mission achieving their definition. Host nation participants used terms such as mutual understanding, collaboration, and commitment to define partnership and almost all felt their definition was achieved. “Working together as a team” was a recurring theme when NGOs defined partnership and like two other units of analysis, their opinions of achievement were mixed. A brief description by unit of analysis is below and a detailed account is found in Appendix P.

Table 10. Partnership Definition Within and Between Units of Analysis

Theme USG PN HN NGO Between Units of Analysis

Tactical Operational Strategic

Working as a team X X X X X X toward a common goal Equity X X X X

Mutual understanding X X X X

Commitment to each X X X other

U.S. Government (Military and non-military participants)

An overarching theme of “two separate entities working towards a mutual goal or goals” was prevalent among U.S. Government participants. Another participant

described partnership in a joint context by stating, “a partnership to me means working together with another entity, strategizing, thinking about goals and outcomes, thinking about methodology together and coming up with joint ways of trying to do things.” The concept of equity was mentioned by one participant when they said, “it’s any sort of a situation where you’re working together in a equal standing, not in a case where we’re instructing their personnel.” The idea of sharing different capabilities was described by two participants. For example, “Partnership means harvesting the different parties that could be involved in a specific purpose or meeting a specific objective and coming to a common agreement on how they would work together and share resources, share knowledge and expertise and work those in harmony and union to meet the objective.”

Finally, partnership was defined as impacting multiple levels when one participant stated,

“I define it as a relationship between people in the lowest level and at countries at the highest level of where you begin to work together, you know each other, you can come to rely on each other.”

In terms of meeting their definition of partnership, opinions were mixed. Some clearly stated, “There wasn’t a sense of necessarily thinking about any sort of sustainable partnership over the time. It was purely to serve a purpose, to get the job done, and I think given that it was the sort of in-out, once the job’s done, people walk away and then the people that they were sort of trying to serve, which is the community and through the

Ministry of Health, they don’t receive any feedback after the task is done. So from my sense, it serves more the purpose of the people who are coming in and not necessarily the objective that it’s supposed to achieve in sustaining a sort of a partnership that the

Ministry feels that they can rely on in the future.” In a similar light, another participant

stated, ““I think the military is great. They really want to do the right thing but this in- and-out doesn’t really lead to anything and there’s a, a naïve but wonderful view by the military, in other words, they gathered all these NGOs and they had charts and Power

Points and they said, “You’ll do this and we’ll do that,” but it’s one shot. They come and they have their meeting and they expect people to be there and people are and they have a good interchange but then after that, it’s really hard to follow up so I’m not sure if anything came of it. Maybe there is but I’m not aware of it.”” Another participant stated,

“For this country it’s just increasing the capabilities. It’d be a long way from a partnership only because they’re still in the crawl phase.”

Other participants claimed their experience fit the partnership definition at specific levels. One stated, “working at like a national level or operational level it probably didn’t change very much but a lot of the experience came from out there in the field.” Another senior level participant claimed, “I think, and it’s not just personal pride,

I would say it did very well at that.” Recognizing previous partnerships may have existed among various participants, one respondent stated, “I think the 2010 mission built new partnerships and improved existing partnerships. If the goal is simply partnership, I think it did a very good job, but I would suggest that possibly the ship visits aren’t just for building partnerships.”

Partner Nation Military (Pacific Region and non-region presence)

Many partner nation military participants used the term equity to define partnership. Specifically, “a partnership is where people contribute equally and both feel that they’re equally valued and that you’re getting something for it as well.”

Additionally, “partnership, to me, would mean having equal footing, equal standing amongst all key stakeholders around the table and actively being a participant in the planning and getting the mission ongoing.” Working together was another concept used to define partnership by partner nation military participants. One stated, “the partnership would be sort of working together as a team to meet some sort of common objective and to sort of share ideas.” The term commitment was also used to define partnership when one participant stated, “it’s a commitment to each other. It’s that sustained relationship over time and it’s that mutual support. It’s the building and strengthening of relationships.”

In terms of achieving the partnership definition, a clear split was evident between operational and tactical level participants. Operational level participants did not feel equity was achieved in the partnership. They stated, “I don’t think it fits the definition very well. I don’t view we were a partner in the mission. I believe we were shipped as just simply participants and our job was to not have any impact on the execution of the mission, just simply ride the mission out and provide a capability that the U.S. Navy or other DOD organization couldn’t do it. We did not have any impact on any part of the execution of the mission.” Another participant stated, ““I found that as a partner nation we were not a key player around the table. We were sort of, you know, “Well, what do you think about this?” but not really, you know we as a nation, view this as, “Look, we’re going to cooperate with the Americans. We’re going to help them fill some bills that they cannot fill but the bottom line is it’s their show.” So we were, even though we were a full partner in the partnership sphere, we were a minor player in the overall operation, and my experience was that regardless the U.S. Navy and the planners on that side would

do whatever their chain of command wanted them to do regardless of input from other partners.”” A third operational level participant explained the gulf in equity by stating, “

I don’t think it could be an equal partnership, you know. This is driven by the U.S.. The

U.S. is funding the mission. They’re providing the platform. They’re providing the rations and quarters, the O&M for the ship. So ultimately, the U.S. Navy is in charge.”

Tactical level partner nation participants overwhelmingly felt their experiences met their definition of partnership. One stated, “exceptionally well” while another stated

“it was fabulous, we were taken in right away as part of the team.” One participant expressed mixed views by stating, “Well, I guess, in 2008 we felt like a small contingent, like a small part of a bigger partnership. It very much was an American-run operation but you did feel that you were contributing very much so. I think the feeling I got with the (partner nation name deleted) were they were very much valued in this partnership.

They saw the (partner nation name deleted) as people who want to have a go and who want to work hard and who always want to seem to be contributing. So I felt that we were a good part of this partnership, but a smaller part.”

Host Nation

Host nation participants defined partnership as mutual understanding, collaboration, and commitment. Two participants mentioned understanding where they defined partnership as, “the interaction between two parties through mutual understanding with the same purposes. What I say, mutual understanding it means that we understand all differences, different difficulties, different technologies, different skills that we have, but we try to work out all of this, and with the mutual trust.” And,

“partnership is, for my opinion, is, you know, it’s improve the understanding each other.”

Fitting within the understanding context, sharing capabilities was used to define partnership by host nation participants. Specifically, “sharing knowledge, skills, experience, learning from each other and, yeah, it’s partnering, sharing knowledge and information between different groups or different people, two people. In this case, between the mission and Timor-Leste health professionals.” One participant said, “the partnership is collaboration, work together between President, the Minister of Health, the government, and other agencies or NGOs.” Commitment was describe by another in their definition of partnership, “a partnership is not only mean that we go together or we sit together but the important thing is how we can have the same commitment and then also the same vision, where we start and where we go. That’s the important part.”

Almost all host nation participants felt their definition of partnership was achieved – “it was very successful.” Many expressed a sense of partnership between the hospital ship mission participants and the communities that they supported. Although the host nation “community” was not considered as a key partner in the planning process, they were an integral partner for the host nation participants. One participant stated, “it was actually very successful in the sense that everybody was involved and excited as well, and even the population were excited because the media got involved.” Another stated, “successful, from my personal vision because those activities that we organize in the district and in sub-district runs very well and also the community, they have the opportunity to receive the humanitarian service and also accommodate those needs that community need and also the important is how the community got the positive response to the mission.” However, one participant did express some reservation in declaring their

partnership definition was achieved. They stated, “we talk about partnership and like something lose in the partnership side, so we go mostly to the humanitarian.”

Non-Governmental Organization (long-term, short-term PP relationship, local NGOs)

“Working together as a team” was a recurring theme when NGOs defined partnership. One participant stated, “partnership to me means like a, it’s 50/50 if it’s two partners, if it’s three, it’s 33 each. It’s give and take. We do something in return for you doing something else. It’s us, it’s one partner contributing the piece of the pie that’s missing.” Another stated, “It’s a two-way process. It’s working together to achieve something, though, in this instance it was to build better relationships.” An understanding of participant capabilities and leveraging one another to meet a common objective was also described as a component of the partnership definition. One participant defined partnership as “a collaboration, a identifying, I guess, in some ways the strengths and weaknesses of different parties and bringing those together and seeing, trying to find, I guess, the best ways to find, to have those offset and the way I look at it is when I look at these development programs that we do, is we do have areas that we’re good at and things that we need support with and then if we can find partners that also have similar needs but on the opposite end, so that our strengths are things they need and vice versa. I think it works out very well, and having more of an equality in a partnership, I think, is important.” There was recognition among NGO participants that

“there’s all different levels of partnership.” Numerous participants repeated the concept of learning in their definition. This was exemplified when one participant said, “What it means to me is that we have mutual exchange of ideas and understanding of each other’s

needs and some input which engenders a response on behalf of all parties, some agreements and not just being told.”

In terms of NGO participant experiences meeting their definition of partnership, opinions were mixed. Positive experiences were described as “it was very good partnership because it involve so many people, so many organizations during the presence of the U.S. Mercy ship in Dili. And different people, different organizations doing different roles, so that was the good things to work together.” Another stated, “just at the ground level, provider standpoint, you could see pieces where this partnership was benefiting.” One participant expressed a mixed experience and stated, “Yeah, I think it did. I think we provided a lot of short-term solutions but not many long.” Many others expressed negative experiences in meeting their definition of partnership. One stated “I can’t see any partnerships because I would’ve thought the partnership is of lasting duration, sustainable, and I don’t think that coming once every two years or so with different people usually is a real partnership.” Another stated, “I would say based on my definition there, I don’t think that was achieved. Better integration would have felt like a partnership and it would’ve felt like it’s reasonable in a sense for the responsibility of follow-up are to be born by the Ministry of the existing system and partners within that system. But you’d need it to feel like a partnership from the very beginning and shared, not shared ownership, ownership is the wrong word, shared responsibility.” Challenges in meeting the partnership definition were attributed in part to different standards of care.

Specifically, “I think it’s difficult to share, to have a true partnership when there’s very different standards from the beginning…I think because we obviously have a much higher standard of care…it’s very difficult if they haven’t got the equipment that we

have. So I think their hospitals aren’t nearly as equipped as ours and they don’t have the medical provisions that we have. So it’s difficult to have a very true partnership.”

Partnership Themes

In order to understand “how” and “why” Navy hospital ship missions influence partnerships, the 15 themes emerging from the key stakeholder interviews were linked to the partnership theoretical framework (Figure 7). Overall, the results suggest hospital ship missions increase connections, facilitate learning, and generate actions among participating organizations that produce impacts at both the individual and overall partnership level. Increasing connections through the partnership assists in opening a dialogue and developing trust, relationships, and credibility among the partners. The theme developing relationships was mentioned by all participants and had the highest number of references in the coded transcripts. Opening a dialogue and developing credibility were themes mentioned by more than two-thirds of participants. Developing trust was mentioned by 57% of participants. Based on the theoretical framework that depicts increasing connections as the first step in the partnership process, having a high number of references to these supporting themes fits conceptually.

The study findings also suggest the partners learn during the hospital ship mission and develop new perspectives, gain a better understanding of partner constraints and agendas, and understand the needs of host nation. Developing new perspectives was the second most cited theme overall by participants. Understanding HN needs, understanding partner constraints, and developing new perspectives were themes mentioned by more than two-thirds of participants. Understanding partner agenda was

mentioned by 62% of participants. These findings also conceptually support that learning occurs after connections are made among the participants while acknowledging it is an iterative process.

The mission also facilitates action among partners that results in the sharing of resources, innovation in how the partnership is fostered, and the ability of partner organizations to achieve their parent organizations objectives. Sharing resources featured in more than two-thirds of the interviews while the other two themes associated with the action construct were mentioned by less than two-thirds. This finding suggests the downstream effects of the partnership as depicted in the theoretical framework are not fully realized among the participants. This shortfall was reinforced by lower response rates to impact related themes. Increased visibility, the sharing of leadership, the performance of new activities, and increased host nation capacity were described as impacts produced by the mission. Although increasing HN capacity featured in more than two-thirds of the interviews, increasing visibility and sharing leadership themes were the least coded.

The 15 themes are listed in Table 11 by the frequency of appearance in the key stakeholder interviews. Each theme is explored in depth below within and between units of analysis. Documentary support for each theme is also provided from policy, guidance, and planning/execution documents reviewed during the study.

Figure 7. Partnership Themes Linked to Theoretical Framework and Ordered by Frequency of Appearance

Table 11. Partnership Themes Ordered by Frequency of Appearance

Theme USG PN HN NGO Between Units of Analysis Interviews where Theme Emerged Military Non- Pacific Non- Long- Short- Local Tactical Operational Strategic High (>66%), Military Region region term term Mod (66%-33%), Presence Low (<33%) Developing X X X X X X X X X X X H relationships Developing new X X X X X X X X X X X H perspectives Sharing resources X X X X X X X X X X H

Understanding X X X X X X X X H partner constraints Developing X X X X X X X X X X H credibility Opening dialogue X X X X X X X H Understanding X X X X X X X H HN needs Increasing HN X X X X X X X X X H capacity Understanding X X X X X X M partner agenda Performing new X X X X X X M activities Developing trust X X X X X X X X X M Generating X X X X X X X X X M innovation Achieving Org X X X X X X X X X M Objectives Increasing X X X X X X X X X X M visibility Sharing X X X X X M leadership

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Developing Relationships

This theme was the most prominent of all themes identified during the key stakeholder interviews. Developing relationships is a plausible element of building connections as depicted in the theoretical framework (Figure 7). This theme featured in all key stakeholder interviews, within all units of analysis, and across all levels of participation (Appendix Q). Among the 164 references coded, operational participants

(42.4%) most often cited this theme followed by tactical (37.2%) and strategic level

(20.4%) participants. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of developing relationships. The theme was triangulated during the documentary review where developing relationships featured in 3 (60%) policy, 10 (83%) guidance, and 3

(60%) planning/execution documents.

Developing relationships was a common theme among US and PN military participants, especially military-to-military relationships. From an organization level, the partner nation military participants nurtured existing relationships with the U.S. military and developed new relationships with other hospital ship mission participants to include

NGOs and partner nation militaries. A USG non-military senior level participant said,

“the relationship between the U.S. military and the Timor-Leste military, I’d say probably in terms of all the partnerships, that’s probably one of the most significant ones that the mission contributed to.” According to host nation participants, relationships are challenging in Timor-Leste, but the hospital ship was successful in developing them between the participants and the Ministry of Health. A senior level participant said, “in terms of relations with the U.S. Embassy and also with the USAID team, it’s an

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opportunity because the Ministry has always new team coming into the system and it’s an opportunity for them to get to know who’s who and that relationship continues afterwards.” The hospital ship mission assisted in developing relationships between the short-term relationship NGOs, the Navy, and host nation personnel. The mission was credited with developing the relationship of the local NGOs with other participants such as USAID, the Ministry of Health, and broader NGO community. Long term relationship

NGOs were mixed in their impression of developing relationships. One participant with experience on two hospital ship missions said, “we’ve got a great working relationship with all the NGOs that partner. It hasn’t expanded into anything beyond that so that may be indicative of something.”

Developing New Perspectives

This theme was the second most prominent theme emerging from the key stakeholder interviews. Developing new perspectives is a plausible element of learning as depicted in the theoretical framework (Figure 7). This theme featured in 33 key stakeholder interviews, within all units of analysis, and across all levels of participation

(Appendix R). Among the 155 references coded, operational participants (42.1%) most often cited this theme followed by tactical (33.9%) and strategic level (24%) participants.

The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of developing new perspectives. The theme was triangulated during the documentary review where developing new perspectives featured in 1 (20%) policy, 7 (58.3%) guidance, and 2

(40%) planning/execution documents.

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New perspectives in conducting HA and about other partners were gained by military participants. A senior level U.S. military participant said, “to develop those relationships and common understandings is good with partner nations, but the other thing is DOD learning how to work with NGOs, learning how to work with State, that’s important different cultures. You’ve probably seen this. We talk differently. We have a bazillion people. They have one. There’s a lot of cultural barriers to communication. So that happens sometimes… I think State and USAID benefit likewise from getting a better understanding or appreciation of what we can bring to the table.” Among PN, the theme featured prominently and focused on the partner nation military learning how to conduct

HA, conduct joint operations, and partner with NGOs. The partner nations also highlighted the U.S. as a learning organization willing to develop new perspective by listening to partner recommendations. Host-nation participants described gaining new perspectives in terms of health services and equipment. One participant stated, “We get some points from them. We learn something new. As you know that East Timor at the moment is very limited in the human resource and so that situation is very helpful, although we know that this is temporary.” Among long-term NGOs, the hospital ship mission facilitated an understanding of the HN needs and the development of new perspectives on how to address them. New perspectives were developed among short- term NGO participants through joint training with other partners, to include the host nation, during the hospital ship mission. Local NGOs developed new perspectives from the military in how to operationalize health services in a rapid fashion and on a large scale. An operational level participant stated, “something that I am full of admiration for,

I have to say, and got us thinking about how we could deliver services differently,

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actually, is the way the military pulls off organizing a clinic in a field and given that, a national initiative called SISCa here is the monthly outreach, trying to deliver services in remote communities. It’s incredibly resource intensive and it’s way off perfect but we’re all working to support it, and then the military team turned up and I got to see these tents and it wasn’t just tents, it was the way the teams organized the community in terms of the queuing, ensuring that the flow of patients was fast, that people weren’t queue jumping, crazy stuff. I know that sounds silly but it was incredibly impressive to watch how, the logistics of setting up an outreach clinic and I did say that to them there. It was quite a thing to behold and I say there are lessons in there for us, given that’s exactly what goes on virtually every day of the month here but it’s chaos.”

Sharing Resources

This theme is a plausible element of generating action as depicted in the theoretical framework (Figure 7). Sharing resources featured in 32 key stakeholder interviews, within all units of analysis, and across all levels of participation (Appendix

T). Among the 88 references coded, operational participants (50%) most often cited this theme followed evenly by strategic (26.0%) and tactical (24.3%) level participants. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of sharing resources. The theme was triangulated during the documentary review where sharing resources featured in 1 (20%) policy and 10 (83.3%) guidance documents.

This theme emerged between U.S. military participants and other participants already working in Timor-Leste as well as with NGOs on the hospital ship. A non-

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military senior official from the U.S. said, “the Australians sent two landing vessels––and so that actually gave us the capacity to sort of reach areas and deliver services to areas that we might not otherwise be able to do and it was significant.” A PN participant described what would occur after a planning conference where they would “come back…and look at our capabilities to see what kind of additional resources we could put on the ship to assist in carrying out the mission.” Through the sharing of hospital ship mission resources, host nation participants were able to support one of their ongoing programs. A senior level participant said the SISCa program was designed, “to make sure that our health staff can visit every village, every house to give assistance once a month but it’s very difficult, this constrain, lots of constraining in part of their role during the rainy season logistically. And then the arrival of the Mercy ships with the huge personnel with the high tech technology, you can easily travel by, fly with the helicopter to every village.” There was recognition among the long-term NGO partners that the hospital ship missions resulted in a sharing of resources although the contribution of each was left to question. A senior level participant with the experience of multiple hospital ship missions said, “the cost of deploying a civilian volunteer is 100% less than deploying an uniformed provider, plus a half-dozen other different measures of MHS effectiveness. So that being the case, why can’t the DOD contribute towards the logistical deployment of civilian providers?”

Understanding Partner Constraints

This theme is a plausible element of learning through the partnership and is depicted in the theoretical framework (Figure 7). Understanding partner constraints

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featured in 29 key stakeholder interviews, within all units of analysis, and across all levels of participation (Appendix BB). Content coded as understanding partner constraints featured prominently between USG (52%) and NGO (33.1%) participant responses. PN and HN made up 9.5% and 5.4% respectively. Among the 90 references coded, operational participants (56.7%) overwhelmingly cited this theme and were split evenly among strategic (22%) and tactical level (21.3%) participants. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of understanding partner constraints. The theme was triangulated during the documentary review where understanding partner constraints featured in 1 (20%) policy and 4 (33.3%) guidance documents.

U.S. military participants identified constraints among themselves and other partners as a result of the hospital ship mission. Non-military participants gained a better understanding of host nation and U.S. government participant constraints as a result of the hospital ship mission. An operational level participant stated, “it was quite a challenge in Timor to get the host government to really see themselves as equal partners in this mission, and that was generally true with both Pacific Partnerships. But that’s, I think not due to a lack of willingness on their part but more to general lack of capacity.”

A strategic level PN participants said, “we got involved at the initial planning conferences where we… would sit down and basically listen to determine where the shortfalls were, or the tasking pressures where the U.S. Navy or other DOD organizations were having when it came to the request for forces that were going to deploy on the exercise.” Host nation participants acknowledge the constraints of their own Ministry of

Health in terms of the partnership. The short-term participating NGO gained a better

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understanding of the host nation constraints and potential impact they would have on building an equitable partnership. The local NGOs were able to gain a better understanding of partner constraints as a result of the hospital ship mission. In particular, the U.S. constraint in taking on more complicated patients was a theme expressed by many as well as the fact no single local NGO has complete coverage of Timor-Leste and collaboration would be necessary to achieve the mission objectives.

Developing Credibility

This theme is a plausible element of building connections as depicted in the theoretical framework (Figure 7). Developing credibility featured in 26 key stakeholder interviews, within all units of analysis, and across all levels of participation (Appendix

S). Among the 59 references coded, operational participants (55.1%) most often cited this theme followed by tactical (26.2%) and strategic level (18.7%) participants. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of developing credibility. The theme was modestly triangulated during the documentary review where developing credibility featured in one (20%) planning/execution document.

U.S. military participants claimed the hospital ship missions facilitated the development of credibility between participating organizations and with the HN population. The latter included building the credibility of the HN military with the HN population. There was a sense among U.S. non-military participants the U.S. developed credibility with the host nation. A senior official stated, “we were able to engage many members of the Timorese Parliament during the Mercy’s visit from the straightforward provision of medical services to those members of Parliament but also by bringing the

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parliamentary leadership onboard they were able to witness first-hand the capabilities that our military has in the area of medical services.” The U.S. gained credibility among partner nation participants for their ability to conduct the mission and in turn, provided credibility to the partner nation for participating. Additionally, NGOs gained credibility among PN participants for their work performance and their willingness to contribute in a volunteer capacity. Partner nation participants also felt their job continuity facilitated relationships that over time matured and yield credibility to the partner nation military.

Credibility was also gained between NGO participants as a result of the mission. An operational level NGO participant said, ““I was a little concerned about the Latter Day

Saints because they had a big contingent, probably sixty people and that’s a religious organization. I’m thinking, “Oh, man, how is that going to work?” And, they turned out to work real well, I mean, nothing against religious organizations but we’re certainly not over there to try and convert people.”” The U.S. military gained a deep level of respect among the short-term NGOs as a result of the hospital ship mission. An operational level participant said, “I think that it’s a fascinating thing to be able to put a hospital together basically in a day with, with all the players coming to the floor at one time. I think that’s a fascinating accomplishment that the scope of the project is so huge, not just for us individually but for the Navy it is rather fascinating that that happens. I think that’s an amazing accomplishment.”

Opening Dialogue

This theme is a plausible element emerging from building connections and is depicted in the theoretical framework (Figure 7). Opening dialogue featured in 25 key

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stakeholder interviews, within all units of analysis, and across all levels of participation

(Appendix AA). Content coded as opening dialogue featured prominently between USG

(45.4%) and NGO (34.8%) participant responses. PN and HN made up 16.5% and 3.4% respectively. Among the 46 references coded, operational participants (46.2%) overwhelmingly cited this theme and were split evenly among tactical (28.5%) and strategic level (25.3%) participants. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of opening dialogue. The theme was triangulated during the documentary review where opening dialogue featured in 3 (60%) policy and 1 (8.3%) guidance document.

According to U.S. military participants, the relationship between hospital ship mission partners facilitated opening dialogue with organizations operating in the HN (e.g. the WHO). The partnership also opened dialogue among individual participants at senior levels that influenced working relationships between participating organizations. In addition, the mission facilitated opening a dialogue with participants who had no prior interaction. A senior level participant commented, “our mission was the first mission of the Japanese JSDF working with NGOs, Japanese NGOs. And…when you talk to them, it was invaluable in making those connections between NGOs and the JSDF. So when it came time to respond to the tsunami, they could do that.” A strategic level non-military

U.S. participant attributed ongoing U.S. military support to Timor-Leste as a result of a dialogue started during the hospital ship mission. A tactical level PN participant observed NGOs collaborating and stated “so there wasn’t just this one NGO over here doing this, one NGO over there. They were actually talking to each other, helping each other out and, yeah, it was fantastic.” According to HN participants, the mission

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facilitated a dialogue between the Ministry of Health and mission participants.

Furthermore, the mission also reinforced an existing dialogue between national, district, and sub-district Ministry of Health personnel. The hospital ship mission created an opportunity for the local NGOs to open a dialogue on a unique topic with the host nation that may have not previously existed. An operational level participant said, ““I think as partners and as guests in this country, in a sense, the onus is on us to sell the idea, not just expect people to say, “Oh, it’s amazing, there’s a big ship coming with loads of operating theaters,” you know. That can sound really wow factor for us but that doesn’t actually mean it’s a wow factor for everybody.””

Understanding HN Needs

63 references coded, operational participants (50.6%) overwhelmingly cited this theme.

Strategic (28.8 %) and tactical level (20.6%) participants made the remaining references during the key stakeholder interviews. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of understanding HN needs. The theme was triangulated during the documentary review where understanding HN needs featured in 4 (80%) policy documents.

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U.S military participants felt the hospital ship mission planning efforts facilitated a better understanding of HN needs. A member of a hospital ship mission pre- deployment site survey team stated, “part of our Advance Party’s work was to work with the Ministry of Health to identify potential surgical cases that we prescreened on our first day.” Working in the host nation as part of the mission also led military participants to understand the HN capabilities and potentially shape future requirements of the partnership. A participant stated, “There’s frankly enough, their medical system, the national, the Ministry of Health is developing enough. Their national hospital system is developing to the point where the real serious surgeries and things like that they can actually handle a lot of those themselves.” A tactical level PN participant said, “it’s a great experience, working with the humanitarian mission and it’s a good experience working with host nations or with partnerships, just to get an idea where they’re coming from.” The long-term relationship NGO said, ““This is Third World and so you can’t really apply your same, I mean, you’d like to say, give people the same quality of care but you really have to, that’s not the right way to say it but I don’t want to say, “Dumb down your medicine,” but, you have to put it at a more basic level. So, the partners that you work with over there, the host nation people, they help you to understand that and you have to be careful not to say, “Oh, my God, how can you do that?””

Increasing HN Capacity

This theme is a plausible impact generated as a result of the partnership and is depicted in the theoretical framework (Figure 7). Increasing HN capacity featured in 25 key stakeholder interviews, within all units of analysis (although marginally among the

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PNs), and across all levels of participation (marginally among tactical level) (Appendix

Y). Content coded as increasing HN capacity featured most prominently among USG participant responses (57.7%). NGO, HN, and PN made up 28.6%, 12.5%, and 1.3% respectively. Among the 78 references coded, operational participants (67.6%) overwhelmingly cited this theme followed by strategic (25.7%) and tactical level (6.7%) participants. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of increasing HN capacity. The theme was triangulated during the documentary review where increasing

HN capacity featured prominently in 1 (20%) policy, 11 (91.7%) guidance, and 1 (20%) of planning/execution document.

A strategic level U.S. military participant said, “I would like to think that that has some long-term impact, even if it just moves the needle one bump, that’s good, and if you keep moving the needle one bump, after twenty years you have a significant change and that, I don’t think any of these missions have an impact immediately. They might have a goodwill impact that lasts for about six months and then goes away but if over the long haul you keep having a significant revisit rate and you keep bringing them along, this,

I’m just speaking the Timorese in particular here, then the better off you’re going to be.

They’re going to be more self-sufficient.” Non-military participants expressed a more modest sense of HN capacity building as a result of the partnership. Partner nation military participants with a regional presence described increasing HN capacity through ongoing training efforts in the country before, during, and after the hospital ship mission as well as their contributions in support of the hospital ship. Among HN participants, the hospital ship mission was credited with increasing HN capacity through knowledge

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transfer and services rendered. A senior level participant described the organizational knowledge gained by one of their directors when they stated, “my small director of the health department is able just to work with the team there and to organize together.

We’re talking about capacity building and then how to work with the others, partners…a very important thing is they come to provide some training for the staff is very important because if they give you the treatment it’s the same but if they give the knowledge, same information, same as for us, it’s very important issue.” Although many local NGOs were critical about the ability of the hospital ship mission to increase HN capacity, they did highlight the cross training of host nation providers and medical maintenance/repair as having an impact. A participant with the experience of three hospital ship missions stated, “the only thing that has been successful for some individuals, a large number of individuals, not a small number and certainly the first, probably the second mission was an element of repair and maintenance of equipment, which was very useful.

Subsequently, we have started developing our own capacity a little bit…they really filled the gap that existed here.”

Understanding Partner Agenda

26.8%, 12.6%, and 3.5% respectively. Among the 59 references coded, operational

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participants (55.8%) overwhelmingly cited this theme. Strategic (30.2%) and tactical level (14%) participants made the remaining references during the key stakeholder interviews. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of understanding partner agenda. The theme was triangulated during the documentary review where understanding partner agenda featured in 3 (60%) policy, 3 (25%) guidance, and 1 (20%) planning/execution document.

Military participants gained a better understanding of the various partner agendas as a result of the hospital ship mission. This included gaining a better understanding of the NGO agenda as described by an operational level participant with the experience of multiple missions when they said, “It is really a complicated issue, there’s a little bit of a dirty side to it, all the fundraising. You kind of get a little disillusioned but it is a business. And working that whole aspect in, when you see Project Hope and you see kids with cleft palates…they put out what it takes to get money to support and grow…They want to be the best NGO, just like all the other ones.” Partner nation military participants recognized each partner organization has an agenda and credited the leadership in synchronizing their efforts to achieve the overarching hospital ship mission goals. A tactical level participant said, ““these groups have agendas and they want what they want to push but I think the leadership there was pretty good about saying, “these are our goals and these are our objectives,” and try to corral us working in a sandbox, so we had some leeway but we had general guidelines to go by.”’ Local NGOs gained a better understanding of partner agendas as a result of the hospital ship mission.

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Performing New Activities

This theme is a plausible impact generated as a result of the partnership and is depicted in the theoretical framework (Figure 7). Performing new activities featured in

23 key stakeholder interviews, within all units of analysis, and across all levels of participation (Appendix Z). Of note, content coded as performing new activities featured most prominently among NGO participant responses (48.4%). USG, PN, and HN made up 24.6%, 22.7%, and 4.3% respectively. Among the 64 references coded, operational participants (56.7%) overwhelmingly cited this theme and it was split evenly among strategic (22.1%) and tactical level (21.1%) participants. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of performing new activities. The theme was triangulated during the documentary review where performing new perspectives featured in 2 (40%) policy and 5 (41.7%) guidance documents.

A strategic level U.S. military participant suggested the partnership has evolved to performing new activities that include capacity building. They said, ““what’s valuable there is that we went from a situation where this was all the benevolence of the United

States, you know. “Look what great things we can do,” just like Lewis and Clark giving trinkets to the Indians. And there has been an evolution and…you’ll see that now there is capacity building that is built into the planning.”” Partner nation military participants described the new activities they learned as a result of the hospital ship mission and how they use the experience to train personnel from their own military. One tactical level participant said, “I think we get to learn all kinds of new things and experience stuff that we don’t typically get a chance to do.” However, although the local NGOs performed

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new activities, they were not linked to ongoing efforts. An operational level participant recalled, “I would describe my NGO’s activities to be very distinct with the Mercy ship from our activities in Timor. And that’s a shame because really they should be part of the same mission, part of the same thing.”

Developing Trust

This theme is a plausible element emerging from making connections and is depicted in the theoretical framework (Figure 7). Developing trust featured in 21 key stakeholder interviews, within all units of analysis, and across all levels of participation

(Appendix X). Content coded as developing trust featured most prominently among

USG participant responses (56.3%). NGO, HN, and PN made up 22.6%, 14.1%, and

6.9% respectively. Among the 43 references coded, operational participants (42.1%) most often cited this theme followed by strategic (31.8%) and tactical level (26.1%) participants. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of developing trust. The theme was triangulated during the documentary review where developing trust featured in 1 (20%) policy, 3 (58.3%) guidance, and 1 (20%) planning/execution document.

One U.S. military participant claimed the hospital ship mission “fostered relationships and it built trust.” The mission also presented opportunities for partner nation military participants to build trust with the various partners through a continued presence over multiple missions. A tactical level participant with experience in multiple hospital ship missions said, “Well, my perception is that maybe the U.S. might have

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valued what we did in 2006 and wanted to offer us a bigger role, maybe they could see that the (country name deleted) wanted to be involved and we had some very good working health professionals who could be put on and maybe that’s why we were offered a bigger role in 2008. And then from there, it’s flowed on, they obviously trusted us with the last contingent.” In a post-conflict nation such as Timor-Leste, a trust deficit may exist between the military and civilian community. The hospital ship mission was described by HN participants as bridging this gap and changing the way the civilian population looks at the military, primarily, the U.S. military. Long-term relationship

NGOs suggested the hospital ship mission assists in developing trust between the partners, specifically the NGOs, U.S., and partner nations. They also highlighted the mission’s bridge gaps where current trust deficits may exist between the NGO and military communities. An operational level participant with the experience of multiple missions said, “the longer we do these, the four, at least the three, the partner nation, U.S. and NGO, I think those relationships continue to get stronger and maybe a lot more trust built between them all.”

Generating Innovation

This theme is a plausible element of the partnership generating action as depicted in the theoretical framework (Figure 7). Generating innovation featured in 21 key stakeholder interviews, in all units of analysis and across all levels of participation

(Appendix V). Generating innovation was equally represented between USG (41.9%) and NGO (37.7%) participant responses. PN and HN made up 17.4% and 3.0% respectively. Among the 21 references coded, operational participants (69.2%)

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overwhelmingly cited this theme followed by tactical (17.8%) and strategic (12.9%) level participants. The frequency of reporting and prevalence within most and across all units of analysis provides reliability and internal/external validity to the theme of generating innovation. The theme was triangulated during the documentary review where generating innovation featured in 2 (40%) policy and 6 (50%) guidance documents reviewed.

Innovation was generated before, during, and after the hospital ship missions.

Instead of conducting independent missions, U.S. military personnel recognized the need to integrate with other partners’ ongoing efforts. Partner nation military personnel stated the hospital ship missions generated innovation in determining who would be involved in subsequent missions and what role they would play. A senior level participant said,

“every year that the planning process continued…more NGO participation was visibly seen. More people were coming to the planning meetings. More people were getting engaged but also host nation countries were being engaged and sending representatives to the planning conferences to have input into what type of services and where these services would be provided in their respective countries. Now when I look back there wasn’t any of that in 2008 and as we moved the yardstick and as the U.S. Navy built up their knowledge base of Pacific Partnership then you started to see more of these organizations coming to the planning meetings and getting engaged.” As a result of the hospital ship mission, host nation personnel gained new perspectives and started thinking about how to address current challenges with existing resources and identify what additional resources might be necessary to achieve their goals. In order to address issues and concerns among NGO participants, the local NGOs innovated by setting up ““an

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NGO group to meet with one another and work out any differences, perceived or real, whether it’s favoritism or, you know, “Why do you get to do this and we can’t do that?” and other stuff, so and that got to be, I mean, it worked, it worked out good.””

Achieving Organization Objectives

This theme is a plausible element of the partnership generating action as depicted in the theoretical framework (Figure 7). Achieving organization objectives featured in 20 key stakeholder interviews, within all units of analysis, and across all levels of participation (Appendix W). Content coded as achieving parent organizational objectives featured most prominently among PN participant responses (36.8%). NGO, USG, and

HN made up 30.5%, 28.5%, and 4.2% respectively. Among the 37 references coded, operational participants (48.3%) most often cited this theme followed by strategic

(29.6%) and tactical level (22.1%) participants. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of achieving organizational goals. The theme was triangulated during the documentary review where achieving organization objectives featured in 1

(20%) policy and 7 (58.3%) guidance documents.

Non-military participants from the USG described the hospital ship mission as achieving the goals of displaying U.S. commitment, providing humanitarian assistance, and building Timor-Leste health capability. A senior level participant stated, “out of my three years of service in Timor-Leste the greatest display of U.S. commitment to Timor-

Leste was manifested through the visit of the Mercy…Just the impact that we had on showing the flag and showing that Americans cared to the average citizen of Timor-

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Leste, including in some very remote areas of the country was exceptional, almost, well, it exceeded my expectations.” The hospital ship missions assisted the partner nation military in achieving their objective of showing their support to the Pacific region and increasing the capacity of their personnel. The hospital ship mission supported the

Ministry of Health in achieving their organizational objectives as stated by a senior level participant, “I want to grant that every citizen of Timor-Leste regardless where they live, those who live in the mountain, in the village, in the valley or in the city shall have the same quality of health assistance. So if you have this belief, this code, you always looking for every sources, every expertise, every assistant that come… those partners can fill the gaps for the Ministry…to bring the service close to the community, to make sure that the community access to the health service, that is very important for us, as well.”

The hospital ship missions assist the long-term NGOs in achieving their parent organization objectives of deploying volunteers internationally, increasing publicity, and gaining HA/DR training. The objectives of the short-term relationship NGO were achieved during the hospital ship mission and included reaching individuals in need and providing another venue for participation of medical volunteers. Local NGOs were able to promote their organization and gain access to a large portion of the host nation population as a result of the hospital ship mission.

Increasing Visibility

This theme is a plausible impact generated as a result of the partnership as depicted in the theoretical framework (Figure 7). Increasing visibility featured in 15 key stakeholder interviews; in NGO, USG, and PN units of analysis; and across all levels of

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participation (Appendix U). It is interesting to note this theme was more prominent between both PNs (43.3%) and NGOs (37%) than USG (19.7%) participants.

Additionally, HN partners did not describe increasing visibility during the key stakeholder interviews. Among the 30 references coded, operational participants (47.2%) most often cited this theme followed by tactical (34.9%) and strategic (17.9%) level participants. The frequency of reporting and prevalence within most and across all units of analysis provides reliability and internal/external validity to the theme of increasing visibility. The theme was modestly triangulated during the documentary review where increasing visibility featured in one (8.3%) of guidance documents reviewed.

A U.S. non-military participant with many years of experience working in Timor-

Leste stated, “the big white ship with the Red Cross is absolutely wonderful, and this is the business side of me speaking. It’s a wonderful marketing tool. When it pulls into a harbor, it’s quite visible and everybody knows that it’s there. And they, you know, if it comes pier side people flock there.” The hospital ship missions assisted the partner nation military in achieving their objective of showing support to the Pacific region. A senior level participant with experience in multiple missions said, “what we were looking for…from the political arena, to wave the flag, to show that (partner nation name deleted) wants to remain an active participant in the Pacific region.” The hospital ship mission supported the short-term NGO by increasing their visibility among the host nation population. One local NGO served as a connector between the hospital ship mission and the Ministry of Health, which increased their visibility and respect. They said, “The

Ministry… considered this implementing partner as very important partner because they can bridge between additional resource and the government.”

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Sharing Leadership

This theme is a plausible impact generated as a result of the partnership and is depicted in the theoretical framework (Figure 7). Sharing leadership featured in 15 key stakeholder interviews, within all units of analysis (although at a lower level in PN participants), and across all levels of participation (Appendix EE). Content coded as sharing leadership featured most prominently among NGO (38.2%) participant responses.

USG and PN were similar at 29.7% and 28.7% with HN coded material making up 3.4% respectively. Among the 33 references coded, operational participants (49.9%) overwhelmingly cited this theme. Strategic (34 %) and tactical level (16.2%) participants made the remaining references during the key stakeholder interviews. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of sharing leadership. The theme was modestly triangulated during the documentary review where sharing leadership featured in 2

(16.7%) guidance documents.

“partner nations don’t normally get to be the lead surgeon…so she did really, really well, purely because of the longevity she was on that ship…it’s the relationships between the heads of the departments that need to be established and if you’re only on the boat for a one country gig, you don’t get that responsibility… what you bring to the party shows the responsibility that you’ll be given.” This participant also described their relationship

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with the U.S. military hospital ship Mission Commander by saying, “we just got on really well and we had been on the ship for some time and he, like in East Timor he made me do a walk sort of walkie-talkie watch you guys run it and then the second one in East

Timor I got to do by myself and then I done a third, there were three in Papua New

Guinea by myself, as well.” A tactical level participant described the experience of her nations military assuming a leadership role over U.S. military participants by saying,

“Well, it was very different in the third contingent because the Americans, sort of the tables had swapped…So they were the embarked forces, rather than us being the embarked forces.” The long-term NGO participants recognized the evolution of the hospital ship missions in providing leadership positions for both partner nation and NGO participants. A senior level participant said, “in 2010 on the Mercy there was actually some of the British or maybe Australian senior officers that were integrated into the ship’s leadership. So they weren’t just partners augmenting medical staff…they were actually fully integrated into the planning and leadership of the ship.” They went on to say, “as we’ve grown together and built more trust, I’ve seen the Navy allow NGO individuals to take OIC roles or site OIC roles, which is a big step I think.”

Facilitators and Enablers Overview

Many factors can facilitate or stymie organizations from joining the hospital ship partnership and also constrain the partnership from achieving their stated goals (Figure

8). The original definition used in this study for partnership facilitator was factors that enable entry to the U.S. hospital ship partnership. Although a few study participants mentioned facilitators in this context, most did not have historical knowledge at an

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organizational level to fully describe these factors. Facilitators to joining the mission included partner nations seeking a regional presence, historical relationships between senior executives of participating organizations, and word of mouth between organizations. Historical relationships between senior executives facilitated membership to the hospital ship missions for a few organizations, but what is less clear is whether the partnership is building links to each participating organizations network outside of the partnership. Enablers of the partnership included historical relationships, host nation receptivity, continuity of personnel, and integration among partners. Facilitators and enablers within and between units of analysis are listed in Table 12. A brief description of facilitators and enablers by unit of analysis is below and a detailed account of representative quotes is found in Appendix FF.

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Figure 8. Facilitators and Enablers Linked to Theoretical Framework

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Table 12. Facilitators and Enablers Within and Between Units of Analysis

Theme USG PN HN NGO Between Units of Analysis

Military Non- Pacific Non- Long- Short- Local Tactical Operational Strategic Military Region regional term term Presence Facilitator PN seeking a regional presence X X X Proximity to U.S. X X X Supportive volunteer employers X X Word of mouth X X X Historical executive X X relationship Enabler Historical relationships X X X X X X X X X X Continuity of personnel X X X X X X X Pre-deployment site surveys X X X X X X X Host nation receptivity X X X X X Supportive leadership X X X X Ship environment X X X X X Integration among partners X X X X X Permissive platform X X X

Expanding role of partners X X X Unique opportunity X X Prior military service X X experience Recurring mission X X

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Facilitators and Enablers within Units of Analysis

U.S. Government

Military participants

Military participants identified the hospital ship vessel and an interest in showing a regional presence as facilitators to joining the partnership. A tactical level participant stated, “I think in the areas where there’s a little mistrust and stuff like that, I think the hospital ship is very benign and is much more recognized, the red cross, as a neutral nonthreatening thing.” Enablers included historical relationships, host nation receptivity, leadership, continuity of personnel, the ship environment, and pre-deployment site surveys/senior leader trips. Historical relationships included military-to-military such as the Australian Defence Force and F-FDTL where there is “such a long-term commitment”, civilian-to-civilian such as USAID and the Ministry of Health as well as

USAID and the local NGOs, and military-to-civilian such as the U.S. military and Timor-

Leste MoH. Having “a level of familiarity” and “knowing what to expect when the big white ship pulled into harbor because we’ve done it before and the expectations were kind of standard” were enablers to achieving the partnership goal. A unique enabler identified was the ship environment when one participant said, “ships, in general, cause camaraderie, natural camaraderie because you’re all eating the same bad food, you’re all there when you’re trying to get on and off the liberty line…so you do have that because you’re all in the same place and there’s a lot of people there.”

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Non-military Participants

The non-military participants identified host nation receptivity as being a key facilitator to joining the partnership. One stated, “the Timorese, actually, have no hang- ups about the U.S. military, cooperating with U.S. military, hosting U.S. military exercises, unlike perhaps some other countries in the region.” Enablers included historical relationships (e.g. Australia and Timor-Leste), pre-deployment site surveys, and leadership. The increasing role of partner nation military was also identified as a facilitator. Leadership was highlighted by one participant when they stated the

“Ambassador like to see that here you are one, no USAID, no military, no state.”

Partner Nation Military

Pacific Region Presence

Partner nation military participants with a Pacific Region presence identified proximity to the U.S. as a facilitator to joining the partnership. This was expressed by one participant when they said, “I know the Canadians will always have a fairly large role, because your countries just work so closely together, I mean, physically, you’re close anyway.” Enablers identified that assisted in achieving the partnership goal included historical relationships, expanding roles of partners, communication and integration between organizations. Specifically, “Every day they would say this is how many people we’ve seen today…so that was actually really good, keeping everyone up to date…everybody really enjoyed that and I think that really helped cement peoples’ relationships and make people think, feel they were a part of something.”

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Non-region Presence

The desire to retain a presence in the Pacific Region and the unique training opportunity were identified as facilitators to joining the partnership. One participant said,

“we have a very small military and it’s, and we do not have the, an opportunity such as

Pacific Partnership to exercise our medical folks using a variety of different platforms such as a Navy ship, landing crafts, helicopters. So for us, it’s a great training opportunity.” Enablers included continuity of personnel, the ship environment, and historical relationships with other military partners outside of hospital ship missions.

One participant stated, “I was very fortunate in the sense that I had the continuity and I had the links already in the various headquarters. So I was able to get a lot of the information a lot sooner than other partner nations, I would imagine and to always sort of be one step ahead.”

Host Nation

Facilitators included host nation commitment and support as well as historical relationships between the various hospital ship mission participants. Commitment was highlighted by one senior official when they stated, “the host nation has a strong commitment, like I can see the government at that time give a strong priority and very supportive of the mission. So at the time, in my position, I also give a strong support, commitment and then if the ministries have strong support and then the government and then the districts will give strong support. So it’s good but probably if the commitment is not there, it’ll be difficult. So it is the political commitment and then support.” Another host nation participant stated “Before the ship arrive we work with (name deleted) from

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USAID…we got many support from the USAID and we have also very good coordination.”

Non-Governmental Organization

Long-term Relationship NGOs

Historical relationships beyond hospital ship missions between CEOs and senior

DoD officials and the permissive hospital ship platform were described as facilitators to joining the partnership. Enablers included historical relationships, continuity of personnel, integration among partners, biennial recurring missions, and retired military volunteers and full-time employees. One participant described his former military status as “a help because the other NGOs kind of looked to us. I think they understood we knew the ropes a little better.” Another participant highlighted the shared leadership among military partners by stating “in 2010 on the Mercy there was actually some of the

British or maybe Australian senior officers that were integrated into the ship’s leadership.

So they weren’t just partners, you know, augmenting medical staff and so on. They were actually fully integrated into the planning and leadership of the ship.” Frequency of deployment was mentioned as an enabler by one participant when they said, “I don’t think the partnership would, there would be anything there, but the fact that these are sustained programs, I think allows that partnership to maintain and sustain.”

Short-term Relationship NGOs

Communication with other other NGOs who have participated on previous hospital ship missions served as a facilitator to joining the partnership. Enablers included

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integrating with organizations previously working in the host nation of interest, a civil- military coordinating council aboard the ship, the ship environment, supportive employers for volunteers, and continuity of personnel. Having the support of employers facilitated the participation of volunteers from NGOs to engage in hospital ship missions.

One participant stated, “My employers were behind me 100% and kept my job open for me. I was there for the four full months and then I took another month off and went to

Australia afterwards and they were very supportive the whole way through.” In terms of continuity of personnel, one participant said “from PP10 to PP12 the Pacific Fleet planners were the same personnel, which tremendously added to the feeling of partnership and the execution, I think, of the planning of the mission.”

Local NGOs

Historical relationships with USAID and the MoH, continuity of personnel between these organizations, as well as pre-deployment site survey meetings were described as enablers in achieving the partnership goal. One participant with experience of multiple missions stated, “the Ministry of Health considered this implementing partner as very important partner because they make bridge, they can bridge between additional resource and the government.” An operational level participant stated, “Now I think it was very positive that the initial meetings were held quite some time before the ship’s planned arrival date and so that did show good kind of preparation.”

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Barriers and Constraints Overview

Barriers were defined as factors that restrict entry to the U.S. hospital ship partnership. It is important to understand barriers in order to inform mitigation strategies that increase the likelihood of organizations joining the partnership. Similar to facilitators, most study participants did not have the historical knowledge to describe barrier in this context. Many participants did describe constraints as factors that prevent the partnership from achieving its goal and can be either external beyond the control of the partnership or internal and inherent to the partnership. Overall, the U.S. military leading the hospital ship mission was identified as a barrier to joining the partnership – specifically among NGOs (Figure 9). Internal constraints to the partnership identified included the short mission duration, resentment among participants, and a lack of personnel continuity. External constraints included low host nation and USAID capacity.

Barriers and constraints within and between units of analysis are listed in Table 13. A brief description of barriers and constraints by unit of analysis is below and a detailed account of representative quotes is found in Appendix GG.

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Figure 9. Barriers and Constraints Linked to Theoretical Framework

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Table 13. Barriers and Constraints Within and Between Units of Analysis

Theme USG PN HN NGO Between Units of Analysis

Military Non- Pacific Non-region Long- Short- Local Tactical Operational Strategic Military Region Presence term term Barriers Military led mission X X X X Internal Constraints Lack of Monitoring and Evaluation X X X X X X X X Short mission duration X X X X X X X Resentment among participants X X X X X X Mission expectations (encounters vs. X X X X X X capacity building) Lack of personnel continuity X X X X X X X Lack of sustained engagement X X X X X X X Dependency on non-local NGOs X X X X X Different standards of practice (civ- X X X X X X to-mil and medical) Personnel turn-over during mission X X X X Language barriers X X X X Volunteers not matching req X X X X Participants lacking HA experience X X X Lack of equity among participants X X X X X Excessive Ambition X X Lack of Embassy medical planner X X X Lack of equity in PA coverage X X Competition among partners X X External Constraints Low HN partner capacity X X X X X X X Low USAID capacity X X Limited HN information X X X dissemination capacity

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Barriers and Constraints within Units of Analysis

U.S. Government

Military Participants

Military participants identified the leading role of the military as a barrier to

NGOs joining the partnership. One participant stated, “Some NGOs don’t go near the

U.S. military and just the fact we’re on a hospital ship, they don’t really embrace our mission.” Internal constraints included the rotation of personnel during and between missions as reflected by a strategic level participants statement, “I don’t think we should rotate all of these staff every month because it’s such a pain in the butt to…orient a bunch of new nurses to the ward…and some of these reservists, boy, they haven’t necessarily practiced actual bedside nursing in twenty years. What are they doing out here?” Many identified the limited amount of time spent with each host nation as an internal constraint.

An operational level participant with the experience of two hospital ship missions stated,

“in medical education it takes years of training and we go in and we have this idea that in just a two week visit we’re going to build capacity. That’s really a hard thing to demonstrate.” Depending on external NGOs as partners and not leveraging local NGOs was also identified. One participant said, “We certainly bring NGOs but a lot of them tend to be a little more like medical tourism…What we really have to do to do a better job in Timor is align with the in-country NGOs.” Multiple military participants identified the lack of a medical planner assigned to embassy; the disparity between personnel requirements versus personnel assigned to the mission by partner nations and NGOs; limited humanitarian assistance experience of senior leaders; the lack of monitoring and

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evaluation of mission impact; excessive USG ambition; and resentment among participants.

Limited host nation military and civilian capacity was identified as an external constraint to the partnership although if capacity building was a stated goal of the partnership, this could be identified as an internal constraint. One participant stated the

MoH was “very eager” with “very good intentions, but poor organization, poor execution.” They went on to say, “as their government matures and becomes more professional that’ll come with time.” Another external constraint was poor communication networks within the host nation as reflected by one participant when they said, “we’re limited by the fact that news does not travel through Timor-Leste.”

Non-military U.S. Government participants

Limited time spent in country was identified as a recurring internal constraint.

One strategic level government official said, “I think the military is great. They really want to do the right thing but this in-and-out doesn’t really lead to anything… It has to be longer, it has to be something that’s started and nurtured and developed and seen through.

A one-off shot or once every year in-and-out is not going to, in my opinion, leave you with a strong partnership.” An operational level participant said, “It’s such a short period of time that it cannot serve as a partnership because it’s not ongoing but what it does do is, I think, de-legitimize the service that the Ministry of Health is trying to do…. countries that are in a sort of transitional state, moving forward with a growing economy need to have more sustained efforts over a longer period of time…rather than a short injection of a mass load of resources over a ten-day period.” Resentment was mentioned

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as a possible internal constraint when one participant said, “if you talk to somebody from

USAID, particularly the people who worked on health, I don’t think they see the Mercy as directly contributing to their health efforts. And probably there’s a little bit of resentment that the DOD has the kind of resources to throw at a, sort of splashy, one- week type mission like this.” Excessive ambition was also identified as described by one participant with the experience of multiple missions, “things could really move fast, much faster than our experiences have been within the Timorese health sector and so what we imagine is happening is that the exercise is taking more ownership of the partnership than perhaps it should.” Another operational level participant said, “they want everything to be planned and delivered with a timeline that is almost like people sending a ship to the moon.” Depending on external NGOs as partners and the lack of monitoring and evaluation were also described as internal constraints.

Non-military partners identified limited host nation and USAID capacity as possible external constraints. One participant suggested USAID, “temporarily bring in somebody else from another mission to actually deal with the military so there’s some sort of liaison between USAID, who’s familiar with military speak and can actually help brief USAID teams and also take the burden off the team that is on the ground because they get distracted.”

Partner Nation Militaries

Pacific Region Presence

Different standards of practice were identified as internal constraints to the partnership. One tactical level participant said their country, “doesn’t use NGOs to

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anywhere near the way that the U.S. does at all. It just doesn’t happen.” Another PN military participant said, “Civilians were a strange bunch. Some of them were incredibly naïve and just didn’t get it and therefore their interactions were pretty reserved…I’d like to say I kept in touch with military. I’ve not kept in touch with any of the NGOs or any of the other civilian agencies.” In the context of medical care standards of practice, a tactical level participant said, “even though you may have these people from all these different countries doing exactly the same job, everybody in all the different countries do it slightly different.” Personnel turnover was described as an issue with partnership impact. A participant rotating on the mission for a shorter duration felt the American’s were not performing to their full capacity. They said, ““a lot of the Americans…were like, “Oh, we finished work at 4:30”…so I thought that was a bit funny because I was like, “Oh, my God, we’re all stuck on this ship, I don’t mind seeing patients ‘til 8:00 at night or whatever.” So but I got permission of my dentist and I was allowed to see patients past closing time, so I was happy with that. I felt like I was still giving it my best, with the time constraints that we had… so I definitely think it was because we were fresh and we were only on there for a short period of time. So we weren’t as worn out, so to speak.””

Non-regional presence

A lack of equity among participants was identified as an internal constraint impeding successful partnership. A participant with experience on two hospital ship missions said, “I believe we were shipped as just simply participants and our job was to not have any impact on the execution of the mission, just simply ride the mission out and

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provide a capability that the U.S. Navy or other DOD organization couldn’t do it.” A unique internal constraint identified was the lack of equity in public affairs coverage.

One participant said, “We understand that this is the U.S.’s show. We understand that but we were not given, I won’t say equal treatment but when we approached the

American Public Affairs people to try to get an article out…it was difficult.” Another participant described a lack of equity in terms of participation by each organization when they said, “Maybe if there was a few more people from each country...I knew there were

Australians there but I didn’t really see them so much. Like definitely, there was U.S.

Navy everywhere, so we were with them all the time but the other countries, there was very few.” The rotation of personnel was identified as an internal constraint to the partnership. One participant said, “one of the difficulties that I experienced with planning from year-to-year was the loss of that continuity. There’d be a staff, a new

Commander, and of course, you know, he would bring his staff and they would have a different way of doing it.” Different standards of practice in terms of how partner nation militaries interact with civilian organizations was also identified as an internal constraint the partnership. One participant said, “The only NGOs that participate in Pacific

Partnership come from the U.S., so our relationship with the NGOs, we don’t have one.

And the only thing we do is we only provide mil-to-mil support.”

Host Nation

Host nation participants were candid and identified their own limited capacity as an external constraint to the partnership. A senior host nation official stated, “It’s a young nation, very limited to resources… the Ministry of Health in Timor-Leste we have

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limitation of capacity, as well, limitation of resource, as well, even we have resource but also how we can look at the resource, organize the resource and also controlling the resource.” Additionally, “in Timor-Leste everything that people do is like we want now, we think about short, medium term. We don’t think long term, and I think the government is trying to work on that to think more in a longer term while also filling the gaps to get there.” A host nation participant claimed the hospital ship participants “have a big group so they can move quickly but for us, like it’s not easy for us to follow.”

A lack of sustained engagement also served as an internal constraint to the partnership. A senior Timor-Leste government official stated, “I would say that perhaps communications afterwards with the mission. I’m not sure whether the doctors that were involved whether they communicate, whether they exchange knowledge, they exchange experience, whether when they experienced challenges at the hospital, whether they contact some of the doctors that were here or even those who stayed to work in the NGOs who’ve collaborated during that period, whether they kept in touch at the same level for exchange of knowledge and experience.” Another host nation official stated, “I can honestly say that after the mission leave and then we don’t have any communication with the Navy. That is one of, how you call it, one of the problem, challenge. I think with the next we need to get a system, when the Navies are here we have a good coordination, good communication, good interaction but after they leave…we don’t know but it’s definitely we need create a communication link.” Host nation participants mentioned language as an internal constraint to the partnership. One strategic level official said,

“The difficulties or the challenges that we face at the moment is related to the diversity of the languages. Some mission there’s some from Canada, some from Asian people, some

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from American, as well, and then Australia, the diverse type of language and then diverse kind of English and then sometimes it make complication to the community.” Similar to other participating organizations, the lack of monitoring and evaluation of partnership impact was described as an internal constraint.

Non-Governmental Organizations

Long-term PP relationship NGO

Political and cultural sensitivities among participants and the idea of a military led mission were identified as barriers to joining the partnership. A participant with the experience of two missions stated, ““NGOs and military there’s always that kind of cultural clash to some degree… health NGOs in particular really focus on long-term sustainable public health projects and these DOD missions, again, outside of the training and the diplomacy and those sorts of things, in terms of the actual care given some argue are even, somewhat dangerous or irresponsible and you can make your own mind up…But a lot of NGOs look at the type of the actual mission work and say, “This isn’t really good public health. This isn’t something that our organization wants to align with.””

Competition among NGO participants was identified as a possible internal constraint. One participant said, “there is some competition between the NGOs and I’ve known that for a long time. That’s what came out of the tsunami, that somehow leads to chaos actually and that’s one of the things that we worked to try and overcome.” A senior level participant stated, “whether you put a box of Band-Aids on or you send thirty volunteers onboard, you’re getting the same level of publicity and credit. And that can be

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a bit frustrating but, everyone understands it and nor do we really want every other NGO to participate because that would take away slots that we would like to fill.” Another participant said, “NGOs, in general, are kind of in a competitive environment and so, I think outside of these missions, there’s no additional activity.” The lack of sustained engagement was described as an internal constraint. An operational level participant said, “DOD likes to present the NGO participation…and it does brief well and I think in theory it’s fine. It’s just finding a way to make the work sustainable and allow the NGOs that are participating, provide them with an opportunity to create a long-term program in- country.”

Resentment among participants was described by a strategic level participant when they said, “I can’t think of a single country where the relationship with USAID has maturely affected any future follow on missions although, we would’ve liked it to and I often hear and feel and experience that these annual military sponsored missions are more an annoyance or an interruption of USAID planned operations than anything else and that they’re basically endured rather than supported. I can’t remember a single one that’s been tied with an ongoing USAID program. Basically, USAID blesses them and says,

“Go ahead,” or gives a recommendation of where or what we ought to do in addition with the indigenous Ministry of Health or health authorities say but I can’t think of a single instance where USAID has followed up or followed through or continued or enhanced any of these ship missions.”

The lack of monitoring and evaluation of partnership impact was an internal constraint. Criticism was levied in the context of health outcomes and the absence of partnership impact metrics. A participant with experience in all Pacific Partnership

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hospital ship missions stated, “That was and still appears to be the measure of success, is the number of patients seen, number of procedures performed, number of surgeries performed, number of pharmaceuticals issued, teeth pulled…what measure of effectiveness or evaluation has DOD used to figure out are these worthwhile? Are they worth the time and money spent and how could they be improved? And I think if you sit down with any public health person there are many ways it could be improved and sustained over the long run with a true partnership. The Navy being the short term, the

NGO, some of the NGO being the long term. I don’t think any of this has been developed.”

The lack of equity among partners was described as an internal constraint. An operational level participant with many years of hospital ship experience stated, “So yes, we are partners but we don’t really have, it’s not an even partnership. It’s, you know, we participate. We get the requirements. We go where we’re told and so on, not a lot of mutual interchange there in terms of country site selection and all of those things…sometimes the reality is a little different than I think what the slides present.”

The rotation of personnel during every mission and misalignment of mission goals were also described as internal constraint to the partnership.

Short-term PP relationship NGO

Military culture was cited as an internal constraint at an individual level that may transcend to the organizational level. A tactical level participant said, “I really don’t think that it was fully understood how incredibly difficult it was for us to interact with the

Navy, with some of their expectations and having to be accountable every minute to

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them.” The short mission duration was also identified as an internal constraint as reflected in one participants statement, “if you could spend longer time there, you’d obviously build better relationships…or if you had, I don’t know, a group that went back afterwards to see how they were getting on, what we’ve learned from each other and then bringing it to the table, making suggestions for next time.” The lack of continuity in personnel between missions was cited as an internal constraint to the partnership as well.

One participant with experience with multiple hospital ship missions stated, “Typically, in these projects there’s new folks every year…they’re reinventing the wheel every year.

All of us in the NGOs are pretty much the same people every year, so there’s a bit of a frustration in dealing with a whole new crew of folks who frankly don’t often know how to pull it off.” They went on to say, “every year we personally feel like we kind of and our team feels like they have to reprove ourselves, that there doesn’t seem to be much institutional memory when I go to the planning meetings, at least for the first one, you know, I’m meeting a whole bunch of new people who have probably heard of (NGO name deleted) but are not really familiar with what we can bring to the party.”

Host nation capacity was mentioned as an external constraint. One participant stated, “I think, in order to have a true partnership you would need equal standards.

Obviously these countries don’t have the medical provision I assume that the U.S. has…so I think there wasn’t a huge amount of medical people there to share information with.” This observation also intersected with differences in standards of care and how they might internally constrain the partnership.

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Local NGO

The lack of partnership impact monitoring and evaluation was identified as an internal constraint. A tactical level participant stated, “it would be nice to have a kind of the evaluation meeting with the Ministry and stakeholders and ask for the feedback because if it is partnership then maybe both, Ministry could do better or the U.S. Navy, they could do better.” One participant described the absence of sustained engagement as,

“it was not clear when they would come back and how they would keep in touch with the

Ministry of Health and the other people and other organizations supported.” Local NGOs also described the dependency upon NGO participants without a HN presence as an internal constraint. One participant with years of experience in Timor-Leste stated,

“2008 was the first time that Operation Smile was part of the ship. And that really caused some problems because they were not aware that our teams had been doing ten years every single cleft in this country, since 2000… and so that was sort of working against each other unknowingly.”

There was also a sense of misalignment of hospital ship mission activities to ongoing local NGO efforts. One senior local NGO official stated, “I suppose I would describe my NGO’s activities to be very distinct with the Mercy ship from our activities in Timor. And that’s a shame, yeah, because really they should be part of the same mission.” Another internal constraint included resentment among partners. One senior local NGO participant stated, “However unsustainable that system is and it’s not designed to be sustainable, so if the Mercy ship is going to kind of continue missions like that, it would be foolish to not try and maximize that. So if USAID and the Embassy believe it’s important then they should put the proper in-country resources behind making

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it a successful mission. The ship coming in and of itself is not enough, in a sense, that’s the easy part, you know. It’s already equipped. It’s already got all the specialists but to make that successful is all the hard work beforehand and so for me, some of the fault would lie, within USAID not doing enough and that’s not doing enough coordination but also specifically with the Ministry and I think if the Ministry don’t see it as important for

Timor, well, then that needs to have some reflection.”

Local NGOs identified limited host nation capacity as an external constraint to the partnership. A tactical level participant felt the Ministry of Health should be leading the partnership, but stated, “I still don’t see the Ministry of Health to come up with some strategy to continue with the collaboration among the partners in the country…without the presence of Mercy ship.”

Documentary Review

The documentary review was conducted as part of the case study after the key stakeholder interviews. This effort served as a formative and triangulation exercise to generate an additional source of data that could validate the key stakeholder interview findings. During the review, it was determined the DoD does not have a single policy or guidance document dedicated to establishing and maintaining partnerships. However, the notion of building partnerships was present in different documents such as the U.S.

National Military Strategy and those used to shape PP08 and PP10 directly and indirectly.

Documents obtained from the study participants included policy, guidance, and planning/execution references. Policy documents were identified as those that specify responsibilities that must be adhered to among the various departments and individuals

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within the parent organization. Examples included the DoD Humanitarian and Civic

Assistance Activities Instruction and U.S. National Security Presidential Directive-44 on

Management of Interagency Efforts Concerning Reconstruction and Stabilization.

Guidance documents were identified as those that provide recommendations or suggestions on how to implement specified policies of the parent organization. Examples included the U.S. Pacific Command Strategic Guidance, DoS Quadrennial Diplomatic and Development Review, the Government of Timor-Leste Strategic Development Plan, and Ministry of Defence and Security National Strategy among others. Planning and execution documents were identified as references used by participating organizations pre, during and post deployment to inform and conduct the hospital ship humanitarian assistance mission during PP08 and PP10. Examples included the DoD Pacific

Partnership Concept of Operations (CONOPS) and post-deployment Command briefings.

A total of 22 documents were reviewed and included 5 policy, 12 guidance, and 5 planning/execution references. Partnership themes from the documentary review that match the case study findings are found in Table 14. Caution was exercised to ensure documents obtained from various partner nation and NGO participants that would compromise their confidentiality were excluded from this list and only information with a classification marking of “unclassified” or lower described. Elements from each document that match the partnership themes were extracted and added to corresponding theme appendices (Appendices Q-BB). These elements were used in triangulating themes that emerged from the key stakeholder interviews.

All 15 themes emerging from the key stakeholder interviews were described either directly or indirectly in the policy, guidance, and/or planning/execution documents.

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These findings are not surprising given the fact 10 themes were discussed in the National

Military Strategy alone. The Chairman of the Joint Chiefs of Staff published this guidance document in 2011 to provide ways and means for the military to advance the national interests defined in the 2010 U.S. National Security Strategy. The National

Military Strategy discussed these 10 themes: understanding partner constraints; understanding partner agenda; developing new perspectives; increase HN capacity; increasing visibility; developing trust; developing relationships; sharing resources; generating innovation; and achieving organization objections. Most policy and planning/execution documents are informed by this strategic guidance and as such, describe these themes in a cascading manner.

The policy documents reviewed did not mention increasing visibility, sharing leadership, or developing credibility. Although these themes are clear elements of successful partnerships, without a dedicated guidance document to partnerships, it is difficult to specify these themes as responsibilities that must be adhered to by the

Services. Seven themes (46.7%) emerging from the key stakeholder interviews were not mentioned in the planning and execution documents. Knowing these documents inform the hospital ship mission pre, during and post deployment, this finding may suggest the following themes are not currently a priority of effort among the partners: understanding partner constraints; understanding HN needs; sharing leadership; performing new activities; opening a dialogue; sharing resources; and achieving organization objectives.

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Table 14. Documentary Partnership Themes Matching Case Study

Theme Policy Guidance Planning/ Execution Developing relationships X X X Develop new perspectives X X X

Sharing resources X X Understanding partner constraints X X Developing credibility X

Opening dialogue X X Understand HN needs X Increase HN Capacity X X X Understanding partner agenda X X X Performing new activities X X Developing trust X X X Generating innovation X X X

Achieving Organization Objectives X X Increasing visibility X X Sharing leadership X

Summary

Part one of this dissertation used a systematic literature review and found: (1) a dearth of Navy hospital ship empirical studies; (2) a scant number of sources describing partnership impact; and (3) the complete absence of diplomatic, development, and host nation primary author publications related to Navy hospital ship missions. Only one publication from partner nation participants was found. Overall, the private sector literature was lacking. The absence of sources focused on the Comfort response to

Hurricane Katrina relief efforts was unexpected.

Part two of this dissertation used an embedded case study of Timor-Leste across two time periods, Pacific Partnership 2008 and 2010. The units of analysis described the

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mission goal in different ways. This variability suggests a lack of common purposefulness. The USG and NGO participants were consistent in their view of mission goals that included building partnerships, providing a training opportunity, and rendering humanitarian assistance. Partner nation participants did not describe the mission goal as a training opportunity. Host nation participants did not identify building partnerships and providing a training opportunity as goals of the hospital ship mission. This inconsistency was also prevalent across units of analysis. Strategic level participants typically captured all three of the perceived goals in their responses while tactical level participants primarily responded to rendering humanitarian assistance. Although building partnerships did not emerge as a common goal within and across units of analysis, there was consistency in definition. However, among the three units of analysis that described building partnerships as a mission goal (USG, PN, NGO), all three had mixed opinions of the mission achieving their definition of partnership.

The fifteen partnership themes emerging from the key stakeholder interviews and documentary review increased our understanding of how Navy hospital ship missions influence partnerships. The themes in order of frequency of appearance are: developing relationships, developing new perspectives, sharing resources, understanding partner constraints, developing credibility, opening dialogue, understanding HN needs, increasing HN capacity, understanding partner agenda, performing new activities, developing trust, generating innovation, achieving parent organization objectives, increasing visibility, and sharing leadership. The themes suggest hospital ship missions increased connections, facilitated learning, and generated actions among participating organizations that produced impacts at both the individual and partnership level.

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However, the results show a delay in downstream effects of the hospital ship mission on generating action and impact.

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Chapter 5. Discussion and Recommendations

Overview

The systematic literature review supported existing criticism of the DoDs need to more effectively measure humanitarian assistance mission impact. Near term research priorities in line with Navy hospital ship mission objectives should attempt to fill these identified literature gaps. Long-term efforts should leverage research collaborations and the findings of this study to objectively explore the effectiveness of Navy hospital ship missions in building regional partnerships and meeting the humanitarian and disaster response needs of a host nation population. Incentivizing or requiring partners to formally document their contributions should be pursued. Conducting rigorous scientific research of Navy hospital ship mission impact commensurate with what is currently employed by the DoD in maintaining and monitoring the health of service members and beneficiaries is realistic and achievable.

This research finds USG, PN, and NGO partners identify building partnerships as a hospital ship mission goal. Efforts to institutionalize the idea of partnership as a goal and develop a common definition among all partners, including the HN, should assist in establishing meaningful and enduring partnerships. The results also showed a delay in downstream effects of the hospital ship mission on generating action and impact among the participants as depicted in the theoretical framework. These downstream effects included generating innovation, achieving parent organization objectives, increasing visibility, performing new activities, and sharing leadership. A direct approach of prioritizing efforts to focus on these themes could be employed now and produce near

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term effects. Without policy, guidance, and planning documents reinforcing these two constructs, achieving downstream partnership effects will remain challenging. In addition, efforts should be made by the hospital ship mission participants to magnify the facilitators and enablers while developing mitigation strategies for the barriers and constraints identified by the key stakeholders.

Overall, the findings suggest an association between the constructs of connections, learning, actions and impacts among the various hospital ship mission units of analysis. However, without clear hospital ship mission goals and partnership definition, “what” should be measured must be identified before developing instruments to determine how to measure. Additional studies should be pursued to validate the findings of this research. The three study aims and a consolidated list of recommendations based on this research are listed in Table 15. All are discussed in depth in the following sections.

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Table 15. Study Aims and Recommendations

Study Aim Recommendations

Study Aim 1. To determine how • Conduct research to fill literature gaps U.S. Navy hospital ship missions • Assess comparative advantage of hospital ships in are evaluated using the literature building partnerships, training military personnel, and from 2004 - 2012 meeting humanitarian needs of a HN population Study Aim 2. To understand how • Establish common mission goals across units of analysis and why U.S. Navy hospital ship and collaboratively develop a partnership definition missions influence partnerships • Prioritize downstream partnership themes o Generating innovation; o achieving parent organization objectives; o increasing visibility; o performing new activities; and o sharing leadership • Update policy documents to reflect partnership Study Aim 3. To validate a • Conduct research to test validity and generalizability of theoretical framework that can be partnership theoretical framework used to improve the measurement o Multiple case study using different countries of partnership effects among visited during PP08/10 hospital ship mission participants o Multiple case study using different hospital ships (Mercy and Comfort) o Explore partnership impact on HN in various stages of transition o Explore partnership impact between developed and developing nation partners o Test partnership framework in contexts beyond hospital ship missions

Study Aim 1. To determine how U.S. Navy hospital ship missions are evaluated using the literature from 2004 - 2012.

How and why U.S. Navy hospital ships deploy has changed dramatically since the

2004 Asian tsunami. This systematic review informs the DoD and partner organizations how each other and the broader international community characterized the hospital ship disaster response and humanitarian assistance missions. The three most significant

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findings of the systematic literature review were: (1) the dearth of Navy hospital ship empirical studies (2) the scant number of sources describing partnership impact and (3) the complete absence of diplomatic, development, and host nation primary author publications related to Navy hospital ship missions. Other findings such as only one publication from partner nation participants, the overall paucity of literature from the private sector, the low proportion of humanitarian assistance publications by the private sector, and the absence of sources focused on the Comfort domestic response to

Hurricane Katrina relief efforts should not be dismissed. Overall, this systematic literature reviewed reinforced the aforementioned criticism of the DoDs need to more effectively measure humanitarian assistance mission impact.

Study Aim 1 Recommendations:

Conduct research to fill literature gaps. Near term research priorities in line with

Navy hospital ship mission objectives should attempt to fill these identified literature gaps. Resources currently exist to accomplish this task. Leveraging internal DoD organizations such as the Center for Naval Analysis and the Office of Naval Research to design empirical research studies in conjunction with other hospital ship humanitarian partners should be encouraged and supported. These organizations as well as others such as the Walter Reed Army Institute of Research employ experts with robust analytical research skills in the health and social science sectors. Collaboration between these internal DoD organizations and external hospital ship partners such as the DoS, USAID,

NGOs, and host nation Ministries of Health must be fostered. The latter organizations

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maintain expertise in monitoring and evaluation and have long histories of development program evaluation. Findings of these collaborative research efforts should be published to inform key stakeholders and the international community of the hospital ship mission impact. Incentivizing or requiring partners to formally document their contributions should be pursued.

Assess comparative advantage of hospital ships. Long-term efforts should leverage these research collaborations and the findings of this study to objectively explore the comparative advantage of Navy hospital ship missions in building regional partnerships, training military personnel, and meeting the humanitarian and disaster response needs of a host nation population. Although patient output numbers during hospital ship humanitarian assistance missions are large and other projects completed perceived effective by mission participants (e.g., distributing eyeglasses and public health classes provided to indigenous populations), their impact on strengthening partnerships or achieving the National Military Strategy objective of strengthening international and regional security is unknown outside of this research. Furthermore, the comparative advantage of the hospital ship in training military personnel in humanitarian assistance and responding to disasters should be explored. Humanitarian assistance training of U.S. military personnel conducted as part of the long standing Joint Task Force Bravo in

Honduras may yield commensurate or greater impact than hospital ship missions. Other

DoD resources capable of supporting disaster response efforts such as modular medical facilities (e.g., Army Combat Support Hospitals or the Air Force Expeditionary Medical

Support) or U.S. Navy gray hull ships with greater lift and the ability to moor closer to shore may reach the population at risk faster and be more cost effective than deploying a

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hospital ship. Conducting rigorous scientific research of the Navy hospital ship comparative advantage commensurate with what is currently employed by the DoD in maintaining and monitoring the health of service members and beneficiaries is realistic and achievable.

Study Aim 2. To understand how and why U.S. Navy hospital ship missions influence partnerships.

Knowing the mission goals as described by the units of analysis was imperative to understand “why” hospital ship missions influence partnerships. It is reasonable to hypothesize individuals or organizations establish partnerships to accomplish a common goal that would be more difficult to achieve in isolation (Boex & Henry, 2001). Bearing this in mind, congruency in mission goals among the four units of analysis was expected.

However, the variability in goals described by the participants, with the exception of rendering humanitarian assistance, suggests a lack of common purposefulness. The USG and NGO participants were consistent in their view of mission goals that included building partnerships, providing a training opportunity, and rendering humanitarian assistance. However, partner nation participants did not describe the mission goal as a training opportunity although this concept was described as a benefit of the mission.

Host nation participants did not identify building partnerships and providing a training opportunity as goals of the hospital ship mission. This inconsistency was also prevalent across units of analysis. Strategic level participants typically captured all three of the perceived goals in their responses while tactical level participants primarily responded to

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rendering humanitarian assistance. Without a consistent goal of building partnerships within and across all units of analysis, accomplishing this objective will challenging. As one NGO participant with the experience of multiple hospital ship missions stated, “for volunteers that don’t understand the concepts of the medical diplomacy and the relationship building and that sort of thing, when they’re there just to help sometimes you got to really manage that expectation.”

Although building partnerships did not emerge as a common goal within and across all units of analysis, there was consistency in how the units of analysis defined partnerships. However, among the three units of analysis that described building partnerships as a mission goal (USG, PN, NGO), all three had mixed opinions of the mission achieving their definition of partnership. A USG participant said, “it serves more the purpose of the people who are coming in and not necessarily the objective that it’s supposed to achieve in sustaining a sort of a partnership that the Ministry feels that they can rely on in the future.” The lack of equity among partners was a key shortfall identified by PN and NGO participants. They highlighted this perspective when describing their experience as “participants” rather than “partners.” Ironically, host nation participants did not describe building partnerships as a mission goal but all participants felt their definition of partnership was achieved. This could be attributed to their definition including concepts such as mutual understanding, collaboration, and commitment instead of equity. Across units of analysis a clear split was evident between operational and tactical level participants. Operational level participants did not feel equity was achieved in the partnership while tactical level partner nation participants overwhelmingly felt their experiences met their definition of partnership. Overall, the

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idea of building partnerships exists among most units of analysis. Efforts to institutionalize the idea as a goal and develop a common definition among participants should assist in establishing meaningful and enduring partnerships.

The fifteen partnership themes emerging from the key stakeholder interviews and documentary review increased our understanding of “how” Navy hospital ship missions influence partnerships. The themes suggest hospital ship missions increased connections, facilitated learning, and generated actions among participating organizations that produced impacts at both the individual and partnership level. However, the results show a delay in downstream effects of the hospital ship mission on generating action and impact among the participants as depicted in the theoretical framework. Without policy, guidance, and planning documents reinforcing these two constructs, achieving downstream partnership effects will remain challenging. In addition, efforts should be made by the hospital ship mission participants to magnify the facilitators and enablers while developing mitigation strategies for the barriers and constraints identified by the key stakeholders. Doing so should increase the participants’ ability to achieve the partnership themes and goal. In total, the study findings suggest hospital ship missions influence partnership among the units of analysis as theorized in the proposed framework. Yet, there are lessons to be learned as they relate to successful partnership.

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Study Aim 2 Recommendations:

Develop common goal and partnership definition. If developing partnerships is truly a hospital ship mission goal, there is a need for the U.S. military to move away from what currently resembles a franchise relationship in which they retain leadership to more of a partnership where responsibility is shared. Developing common goals and a clear partnership definition among hospital ship mission participants would be a positive step toward sharing leadership and essential to partnership development. Senior leaders within each unit of analysis should jointly develop and publish mission goals and a partnership definition that would result in a symbiotic relationship yielding interdependence. This interdependence would produce a level of commitment and trust among all participants in meeting the partnership goal and trickle down from the strategic to tactical level (Kumar et al., 1995).

Prioritize downstream partnership themes. Setting common goals and definition among all participants should generate results over time. A direct approach of prioritizing efforts to focus on themes related to partnership action and impact that did not feature prominently during the study could be employed now and may produce near term effects. These themes include: generating innovation, achieving parent organization objectives, increasing visibility, performing new activities, and sharing leadership. Focusing on these themes could mitigate internal constraints identified by participants such as short mission duration, lack of personnel continuity, and resentment among participants while achieving downstream partnership effects. Examples of how this could be achieved are listed below.

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Generating innovation: Military resources in developing countries may be limited in capacity and capability. As of August 2012 approximately 1,800 personnel were assigned to the F-FDTL in Timor-Leste. Of these, approximately 50 were medics with basic emergency medical technician skills, 11 physicians, and approximately 100 engineers. During hospital ship missions, host nation militaries are looked upon to provide medical, engineering, security and other personnel to support the mission.

Should their resources be limited, there is significant value added in pursing the support of National Police elements to meet the mission security requirements. In doing so, the hospital ship partners will be exposed to and integrated with another sector in the host nation.

Local Timorese expressed mixed opinions of the police force. Some in the general population fear the police and look upon them with disdain based on recent allegations of human rights violations against the population. However, the United

Nations and other bi-lateral police training efforts are working to legitimize the National

Police in their efforts to ensure democracy and guarantee the security of all citizens in a non-partisan manner. Being a critical and accountable host nation partner in support of hospital ship missions may assist in changing the perceptions of the National Police by the host nation population.

Leveraging police in lieu of military personnel to provide security in less stable environments could lighten the burden placed upon the military and allows them to focus their efforts on providing humanitarian assistance to the local population. Through the collaboration of host nation police and military personnel during hospital ship missions, their legitimacy among the host nation population may be increased. Expectations

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regarding National Police actions consistent with international law and in support of the hospital ship mission can be articulated, agreed upon, and enforced. These actions would include security support to teams deployed from the hospital ship inland to remote sites where they conduct MEDCAPs and VETCAPs as well as supporting crowd control requirements in the major port city where the ship is docked. This subtle, but vital articulation and enforcement of security expectations is important in post-conflict and developing nations such as Timor.

Furthermore, incorporating host nation police and military participants could increase the trust between these organizations. In developing countries where both organizations may compete for limited security sector resources from their government and international donors, building trust between hospital ship partners from the host nation is vital. The potential increase in communication and trust between the police and military theoretically should be replicated between these host nation actors and other partners in the hospital ship missions. Although sustainability of the partnership remains to be measured between the actors, the potential for new partnerships to grow and offset existing requirements is great.

Another consideration impacting the partnership is the short mission duration.

Participants unanimously acknowledged the limited amount of capacity building that can be achieved using the average two-week mission template. The short duration poses challenges for post-conflict nations such as Timor-Leste with limited resources to perform as an equal partner. As such, experience suggests the U.S. military and other partner nations assume a greater role in order to accomplish the mission. If a true partnership exists between the various hospital ship mission participants, these finding

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should generate innovation. Lessons could be learned from Mercy Ships, the largest international NGO operating a hospital ship.

When deployed to developing country ports, their ship remains on site for up to

10 months to address the medical needs of the population and build capacity of the host nation medical personnel through training programs conducted both on and off the ship.

Longer duration missions will limit the number of nations visited by the U.S. hospital ships; however, the partnerships generated may be more meaningful and lasting. This concept is similar to one suggested by Welling et al (2010) in describing sins of humanitarian medicine when they said, “It is better to pick one country and continue to serve it well, than to hopscotch all over Africa, going everywhere and truly getting nowhere.”(Welling et al., 2010) This longer duration could more effectively support ongoing development efforts within the HN in partnership with hospital mission participants and other actors representing different sectors and nations in Timor-Leste. In doing so, the hospital ship mission will mirror the Cuban approach to capacity building in

Timor-Leste which is focused on long term cooperation as a matter of solidarity between populations, not driven by financial flows or leverage (Anderson, 2008).

Achieving parent organization objectives: The shortfall in USG and NGO participants achieving parent organization objectives as a result of the hospital ship mission centered on their perception of limited partnership and health impact. The hospital ship mission developed military-to-military partnerships; however, the missions’ impact on civilian-to-civilian and civilian-to-military partnerships was limited. This research effort sought to address the partnership impact shortfall and validate a theoretical partnership framework as described in Study Aim 3 below. In the context of

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health impact, The RAND Corporation and the U.S. Navy Bureau of Medicine have develop methods to quantify health impact (RAND Corporation, 2011)(Department of the Navy, 2011). Another concept beyond their efforts to assess health impact used cost benefit analysis and emerged in discussion with PP08 participants. Participants collected data capturing the numbers and types of activities performed during PP08. Estimated cost savings were calculated using domestic Diagnosis Related Groups (DRG) and

Relative Value Units (RVU).

Building on this novel concept, HN cost avoidance estimates could be generated for activities and procedures provided on future missions. Average unit costs per inpatient service and surgical procedure as calculated during the 2008 MoH Hospital

Costing Study for the National Hospital and five referral hospitals in Timor-Leste could be matched to services provided both on board the Mercy and ashore at each of the mission sites. The total number of surgeries performed could be converted using unit cost per surgical procedure for the National Hospital in Dili. Unit costs for laboratory, radiology, ICU recovery days on board the Mercy could also be calculated for services provided should the data be available. Ashore MEDCAP missions could be matched to the closest referral hospital and each patient provided medical services during the mission categorized as an outpatient visit and cost estimate generated. The overall calculation would provide a cost estimate of medical services conducted during the hospital ship mission using Timor-Leste Ministry of Health rates. The estimate could be compared to the annual MoH operating budget to gain a sense of cost avoidance if the MoH provided the services in lieu of the hospital ship mission.

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Increasing visibility: Partner nation military participants highlighted the desire to increase their regional presence as a facilitator to joining the partnership. However, examples were cited where PN participants requested the support of US public affairs to increase their amount of print and video coverage to help achieve this objective and it was not provided. Conversely, the long-term relationship NGO felt there was too much equity in terms of visibility. One participant with the experience of multiple missions said, “there’s a lot of NGOs that do participate and get their logo on the PowerPoint slide that are really just providing some supplies…or maybe like the Rotary Club, they maybe have in-country interpreters that aren’t necessarily deploying anywhere.” Finally, a senior level military participant reflected on the comment of a general officer when they said “Maybe we need to be a little less showy and we need to feature the local Mayor and local person because by making that Mayor or that Minister of Health look good, we strengthen that country by strengthening the support that the citizens have towards their government.” Ironically, the HN participants themselves did not identify with the need to increase their own visibility, which may be a cultural standard. Bearing in mind the various level of visibility desired and achieved, the Navy should consider embarking partner public affairs officials or assume the responsibility for increasing the visibility of all participants. Ensuring all are represented in print, video, and audio coverage in an equitable manner should be a minimal standard. Each participating organization provides a specific service that meets a requirement of the partnership. Although the contribution may not be equitable in terms of resources, highlighting their comparative advantage in an equitable manner will empower the participants and further support achieving the hospital ship mission partnership goal. Furthermore, increasing the visibility of each

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partner in a methodical manner may reduce the internal constraints of resentment and competition among various partners.

Performing new activities: NGO participants described half of all references coded as performing new activities. This finding suggests NGOs are learning as a result of the partnership and employing skills obtained toward new activities in the partnership.

A culture of deliberate and slow change among US and PN military participants may preclude turning new activities observed or conducted into follow-on missions. A significant internal constraint identified to the partnership is the lack of continuity among individual participants. Using the same individuals on future missions may be more important than leveraging the same organizations especially with the HN where individual relationships are so vital. Expanding the role of local NGOs could fill this gap.

Leveraging international NGOs currently operating in the host nation through

USAID to support hospital ship missions proved to be a vital component of the missions.

This aspect of the NGO “partnership” is often overlooked as they do not actually travel on the hospital ship to each country visited during the mission. They typically speak the local languages; have a robust understanding of the various cultures, and long standing relationships with the MoH. At times, they are the initial face of the hospital ship mission to the host nation population. Using local NGOs already working in the host nation also reduces costs associated with deploying NGOs on board the USNS Mercy and extends the capability and reach of activities performed in the country. Although there may be a need for technical expertise beyond local NGO capability, they routinely have the essential connections with the local government through the MoH and other formal

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and informal social networks. Their influence extends beyond the national to district and community levels and is vital in planning and executing outreach missions.

Although the host nation population was not explicitly identified as a partner in the hospital ship mission, their perception of treatment impacts their relationship with the local NGOs. When individuals are denied health care from the hospital ship, their opinion of the hospital ship mission partnership to include the HN Ministry of Health and local NGOs is tarnished. Denial of services could be based on existing infectious diseases such as TB or lack of follow-on care to support intensive surgical interventions on the hospital ship. Individuals may become frustrated and angry toward the local NGO and more broadly the hospital ship partners when they must return to their community without receiving medical services. Many times, this journey can take several days and has direct and indirect costs for the individual and their family. The combined lack of medical services received and high individual costs incurred as a result of making the journey may undermine the relationship between the local NGO and host nation population. This frustration could foment and undermine the local NGOs belief in and support for the hospital ship partnership.

The NGO suggestion of adding a goal to provide sustainable solutions to include training of HN personnel is admirable and can be directly tied to an explicit purpose of the partnership. It was felt by local NGOs that “the system was not in place, it would have been nice to transfer skills to the Timorese people.” Many programs and activities within the DoD are tied to “building partnership capacity” efforts and the hospital ship mission would fit within this context. Doing so would force long term engagement between the myriad participants and enable a lasting partnership between the various

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actors. This long-term goal linked to capacity building and health outcomes could afford additional opportunities to build meaningful civilian-to-military relationships with the different hospital ship mission partners. Based on the local NGO feedback, the onetime hospital ship mission does little to build this partnership. Furthermore, it was felt that

“one short event without follow-up does little to build HN capacity.” Developing this long-term goal with the various hospital ship partners could further enable the partnership beyond one-time hospital ship missions and lend itself to more robust relationships and outcomes.

Sharing Leadership: In order to address the barrier of a military led mission, mitigate the internal constraint of lacking equity among partners, and encourage the enabler of expanding the role of partners, the U.S. Navy should pursue sharing leadership of hospital ship missions. The PN participants recognized the Navy as a learning organization when they allowed the Australian Defence Force to lead the Pacific

Partnership 2010 mission to Papua New Guinea using their own ship with embarked partners to include the U.S. military. This specific leg of the PP10 mission did not include the Mercy; however, did pursue similar goals of providing HA support to the local population and building partnerships. Long-term NGO participants conveyed similar remarks when highlighting the U.S. Navy allowed individual NGO representatives “to take OIC roles or site OIC roles, which is a big step.” These two examples highlight the ability of partners to effectively take on various leadership roles at different levels. In doing so, equity is shared among the partners and the roles of the partners are expanded. The latter also led to an increase in resources invested in the partnership by PN participants (e.g. ships and personnel).

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Additional consideration should be given to the leadership role of the DoS and

HN personnel within the countries visited during the hospital ship missions. Participants representing different levels within the USG (DoD and USAID), PN, and NGOs (long- term and local) highlighted the heavy hand approach of the DoD in assuming leadership of the mission when the Ministry of Health did not meet their compressed timeline.

Furthermore, a local NGO participant with experience of both gray hull and white hull missions felt undue pressure was placed upon the Ministry of Health during hospital missions to take the lead for their country while the Ministry of Defence and Security would assume the lead for gray hull missions. Encouraging a greater U.S. DoS and

Timor-Leste Ministry of State and Foreign Affairs leadership role in country may support a true whole of government approach for both nations during these missions. The historical relationship between these partners should enable a more successful mission in the near term and yield a greater partnership impact in the long-run.

Increasing the role of the DoS as a leading partner may also support an increase in shared resources. Given the fiscal constraints of the DoD that led to the cancellation of the 2013 Continuing Promise hospital ship mission, DoS may be able to provide financial assistance to sustain these missions. As one DoS participant stated, “I think out of my three years of service in Timor-Leste the greatest display of U.S. commitment to Timor-

Leste was manifested through the visit of the Mercy…Just the impact that we had on showing the flag and showing that Americans cared to the average citizen of Timor-

Leste, including in some very remote areas of the country, was exceptional, it exceeded my expectations.” Consistent with this view, other partners felt the DoS received the

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greatest return on investment during these missions and could increase their financial support in a more equitable manner.

Update policy documents to reflect partnership . Policy documents such as the

Joint Publication 3-29 published in 2009 defining DoDs role in foreign humanitarian assistance repeatedly describe NGOs, international organizations, and other hospital ship mission organizations as nothing more than “participants” in foreign humanitarian assistance. The key stakeholder interviews reinforced the perception among hospital ship mission partner nations as being more of a participant in the mission than a true partner.

This publication also stated DoS and USAID will work with NGOs and other private sector partners who share USG objectives. It leads the reader to perceive partnerships as military-military and civilian-civilian with the exception military-to-civilian within the

U.S. Government interagency. The DoD and other hospital ship mission participants should modify the language in their current policies, guidance, and planning/execution documents that relate to partnership from “participant” to “partners.” This subtle, yet meaningful change could shift the current mentality among various participants to a partnership focus.

Study Aim 3. To validate a theoretical framework that can be used to improve the measurement of partnership effects among hospital ship mission participants.

The embedded case study design across two-time periods met the conditions for testing the hospital ship partnership framework and in general, supported the theory (Yin,

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2009). Studying the same embedded case at two different points in time provided insights into how certain partnership themes changed over time and their potential enablers and constraints. Using USG, PN, HN, and NGO units of analysis from the same case also provided greater opportunity for extensive partnership analysis among the various actors representing different sectors. These embedded units enhanced the understanding of how and why hospital ship missions influence partnership as depicted in the theoretical framework. The findings suggest an association between the constructs of connections, learning, actions and impacts among the various hospital ship mission units of analysis.

However, without clear hospital ship mission goals and partnership definition, “what” should be measured must be identified before developing instruments to determine how to measure. Additional studies described below should be pursued to validate the findings of this research.

Study Aim 3 Recommendation:

Conduct additional research to test the partnership theoretical framework.

Although this research assessed the partnership impact of the USNS Mercy mission in

Timor-Leste (a post-conflict nation), the findings should be generalizable to other countries visited during PP08 and PP10 and more broadly to other Mercy missions.

However, the historical context in Timor-Leste preceding the 2008 and 2010 missions may require adaptation of the theory to countries being engaged for the first time. These generalizations are not spontaneous, but if tested using a multiple case study design and similar results are found, this provides external validity to the theoretical framework and

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study findings for Mercy hospital ship missions. A similar study focusing on the USNS

Comfort during Continuing Promise missions in Latin America and the Caribbean could also substantiate the external validity of these findings to all U.S. Navy hospital ship missions.

Future studies should also explore the partnership impact on host nations in various stages of transition from recent post-conflict (e.g. Timor-Leste) to developing nations (e.g. Vietnam). Each phase has different needs in terms of the partnership and what type of assistance is rendered. Post conflict nations may require more direct humanitarian assistance whereas developing nations are better positioned to engage in capacity building efforts. Assistance contributed by each organization in the partnership can also vary in terms of leadership, resources, and speed. In disaster response and humanitarian assistance phases, speed in collaboration, response time, and ability to mobilize external resources are essential. These conditions may demand a shift in partnership leadership with external partners (e.g. partner nations and NGOs) playing a leading role in coordinating and leading the response effort with facilitation from the host nation. In development phases, existing relationships among the participants may demand greater contributions from the host nation. Leveraging resources currently in the host nation with whom the ministries have long standing relationships would be feasible and more practical. The host nation ministries are better positioned and more capable in terms of capacity to lead the routine humanitarian assistance mission and development activities. Furthermore, the host nations could teach other organizations within the partnership how to facilitate transition between crises and development stages. They have first hand experience dealing with challenges in isolation and in conjunction with

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the international community. The partnership would gain a better understanding of the various international actors and capabilities and various metrics that could be used as triggers to shift priorities of effort as the host nation assumes greater responsibility in the partnership.

The idea of partnership impact variability at different stages of HN transition could also exist between developed nation participants (e.g. US and partner nations) and developing nations (e.g. host nations). Previous studies suggest knowledge and innovation from developing countries such as Timor-Leste may not be appropriate for or even transferable to developed countries such as the United States. However, through the partnership-learning construct, knowledge can be shared between the partners to improve both the partnership and ultimately health outcomes of their respective nations. The latter implies health outcomes of not only the host nations visited during the hospital ship missions, but the U.S. and partner nations as well. Testing this concept should be a next step.

Finally, the partnership theory could be applied to other contexts beyond hospital ship missions where the USG partners with similar international public and private actors to support health and public diplomacy efforts. One example could be the DoD overseas labs where they partner with Ministries of Health, Ministries of Defense, academia, and international organizations among others in pursuit of force health protection research and development that supports the global good (J. Peake, Morrison, Ledgerwood, &

Gannon, 2011). This program provides a unique opportunity to validate the partnership theory beyond hospital ship missions and could bridge the rift with humanitarian actors while establishing, enabling, and sustaining meaningful partnerships with the U.S. DoD.

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Strengths and Limitations

This is the first study to empirically identify how the various hospital ship participants and international community evaluate hospital ship missions. Furthermore, this is the first study to scientifically assess through rigorous methodology the partnership impact of U.S. Navy hospital ship missions. The qualitative embedded case study design was ideal for the research questions that required an understanding of the various participants’ views and the case study provided a distinct advantage in answering the how and why research questions (Green & Thorogood, 2009; Yin, 2009). Through the use of triangulation of multiple data sources (systematic literature review, key stakeholder interviews, and documentary review), the various views of hospital ship mission partnership impact were compared and corroborated. The specific embedded case study design met the conditions for testing and confirming the hospital ship partnership theory and the four embedded units of analysis presented further opportunity for extensive analysis (Yin, 2009). Including the four units of analysis representing the various hospital ship mission participants ensured all aspects of the partnership were revealed and understood both within and between the participating organizations (Baxter & Jack,

2008). Using multiple units of analysis with sufficient representation among the various levels of involvement among all countries visited by the USNS Mercy during the PP08 and PP10 missions increases the richness and generalizability of the findings to other countries where the Mercy deployed as part of PP08 and PP10 or more broadly, to missions where the USNS Comfort may deploy in the future. Additionally, the partnership theory could be applied to other contexts beyond hospital ship missions

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where the USG partners with foreign nations, host nations, and NGOs to support health and public diplomacy efforts.

In order to ensure the internal validity of the study findings, this research specified units of analysis and a theoretical framework prior to data collection. Relying on partnership theoretical propositions to guide data analysis of information collected from the various mission participants ensured the evidence was treated fairly and produced compelling analytic conclusions (Yin, 2009). This approach is common in qualitative studies and allowed the PI to test the internal validity of the theory during the data analysis process. Furthermore, by using multiple sources of evidence during data collection and analysis which included the systematic literature review, key stakeholder interviews, and documentary material review, convergent lines of inquiry were explored further increasing the internal validity of the research findings with reality (Yin, 2009).

The reliability of the research findings was supported through the consistent and thorough documentation of all procedures conducted throughout this research ensuring the replicability for future studies. Documenting all systematic literature review steps in accordance with the IOM protocol provides complete transparency in what references were excluded and included in the analysis to reach objective results and conclusions.

Using a published embedded case study protocol that included an IRB approved interview guide based on the a priori theoretical framework, conducting specific field procedures such as presentation of credentials through IRB approved telephone/email introduction scripts as well as the language used to protect human rights in the IRB approved informed consent form further increases the reliability of the research findings.

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In addition, this research minimized selection bias through the balanced representation across all units of analysis from the policy, operational, and implementation levels. Incorporating participants from the diverse range of partners representing different levels of involvement during the two missions also increased the richness and generalizability of the findings between each unit of analysis and among the different countries visited during the missions. This richness was further increased with

32% of the key stakeholders interviewed having participated in both PP08 and PP10 missions and able to provide historical perspectives and experiences of changes over time. These research approaches, which minimized selection bias, facilitated reliability, and ensured internal validity, all came together to support the analytical generalizability of the findings. The scientific rigor of this research effort supports the legitimacy of the findings and recommendation presented here.

General limitations to the case study method and the mitigation strategies employed during this research were described in Chapter 3. Although efforts were made to interview HN military participants, this shortfall should be explored in future studies.

Overall, the research findings supported the hospital ship partnership theoretical framework and provide a method to measure partnership impact – the first of its kind for the DoD.

Conclusion

Politicians often leverage health services provided by Navy hospital ships to meet diplomacy efforts. Using hospital ships to meet political objectives may in fact undermine and or place a heavier burden upon health efforts managed by the

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development community – to include the USAID and NGO partners. As the global economic crisis forces states like the U.S. to reduce their military sector investment, hospital ship humanitarian assistance missions may decrease in number and frequency to make up for the projected budget cuts. This should force individual states to increase their investment in civilian capacity to meet the growing humanitarian and disaster response requirements instead of perpetuating the ad hoc use of military forces as a gap solution (The United Nations, 2003). Eliminating the military sectors role in humanitarian assistance is not being suggested; rather focusing efforts where they are required as identified in international agreements such as the Geneva Conventions and maintain a comparative advantage is a more appropriate investment.

If the DoD continues to deploy hospital ships in an effort to build regional partnerships, employing the aforementioned recommendations will move the ships and their efforts on course. Furthermore, the partnership theoretical model developed through this rigorous research effort will help the DoD quantify partnership impact. Publishing policy, guidance, and planning documents reinforcing the downstream partnership effects will buttress these efforts. Magnifying the facilitators and enablers while developing mitigation strategies for the barriers and constraints should be initiated immediately.

Now is the time in this era of global fiscal constraints and a shift toward international partnerships for actors participating in Navy hospital ship missions to objectively measure their impact. The participants and beneficiaries of services provided during these missions as well as the American taxpayers that fund them deserve nothing less.

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Appendix A. Systematic Literature Review Coding Sheet

1. Title: 9. Actual Mission 2. Year of publication: • Continuing Promise=1 3. First Author: • Pacific Partnership=2 4. Article country of origin • Tsunami Relief=3 • US=1 • Earthquake Response=4 • Non-US=2 10. Primary focus area 5. Type of publication • Exercise/training=1 • Journal=1 • Medical care=2 • Book=2 • Dental care=3 • Book chapter (in edited book)=3 • Veterinary care=4 • Dissertation or thesis=4 • Partnership/collaboration=5 • Technical report=5 11. Research methodology • Conference proceedings=6 • Quantitative=1 • Other (e.g. editorial)=7 • Qualitative=2 6. First author affiliation • Mixed methods=3 • Public=1 • Other (e.g. editorial)=4 • Private=2 12. Detailed methodology 7. Sector • Experimental=1 • Health sector=1 • Non-experimental=2 • Military sector=2 • Quasi-experimental=3 • Diplomacy sector=3 • Narrative=4 • Development sector=4 • Phenomenology=5 • Profit=5 • Grounded theory=6 • Not for profit=6 • Ethnography=7 8. Mission type • Case study=8 • Humanitarian assistance=1 13. Study setting (country) • Disaster response=2 14. Outcome results • Construct measured

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Appendix B. Key Stakeholder Recruitment Scripts

Email:

Dear (potential study participant name):

You are invited to participate in a research study conducted to inform the U.S. government and its partners of the influence U.S. Navy hospital ships have on strengthening partnerships.

The U.S. Naval Ship Mercy mission to Timor-Leste during Pacific Partnership 2010 will be used as the case study. Factors impacting partnerships will be explored to develop a theoretical framework to inform future hospital ship missions.

If you choose to take part in this study, you will be asked to join me for an in-person interview at a date and time convenient for you. Should an in-person interview not be feasible, a telephonic interview may be conducted. The information you provide will be kept completely confidential. Neither your name nor the organization you work for will be reported. The total amount of time you will spend in connection with this study is approximately 60 minutes.

Attached are letters of endorsement for the study from the Minister of Health for Timor- Leste and USAID Mission Director to Timor-Leste. Also attached is The George Washington University Investigational Review Board approved informed consent form that provides additional background information.

Please let me know if you have any questions and thank you in advance for considering this opportunity. I look forward to hearing from you.

Respectfully, Derek

Derek Licina DrPH(c), Global Health Major, U.S. Army The George Washington University 2175 K Street NW, Suite 200 Washington, D.C. 20037 931-302-8609

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Telephonic:

Hello (potential study participant name).

My name is Derek Licina and I’m a doctoral student here at The George Washington University in Washington, D.C. I would like to invite you to participate in a research study being conducted to inform the U.S. government and its partners of the influence U.S. Navy hospital ships have on strengthening partnerships. The U.S. Naval Ship Mercy mission to Timor-Leste during Pacific Partnership 2010 will be used as the case study.

Do you have a minute for me to tell you a little more about the study?

If yes, continue script below.

If no, if you are interested in learning more at a later time, please let me know what time would work best. If you are not interested. I certainly understand and respect your decision.

Thank you very much. We are interested in exploring factors that impact partnerships to develop a theoretical framework and inform future hospital ship missions.

I understand you participated in the Pacific Partnership 2010 hospital ship mission to Timor-Leste and if you choose to take part in this study, you will be asked to join me for an in-person interview at a date and time convenient for you. Should an in-person interview not be feasible, a telephonic interview may be conducted. The information you provide will be kept completely confidential. Neither your name nor the organization you work for will be reported. The total amount of time you will spend in connection with this study is approximately 60 minutes.

I have letters of endorsement for the study from the Minister of Health for Timor-Leste and USAID Mission Director to Timor-Leste. Additionally, The George Washington University Investigational Review Board approved the study’s informed consent form that provides additional background information. I would like to send you a copy of these three documents and my contact information via email if you could provide an email address.

If you don’t have any questions of me, could we schedule a time for the interview that works best for you?

Thank you for your willingness to support this research effort and I look forward to talking with you again soon.

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Appendix C. USAID Mission Director Letter of Support

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Appendix D. Timor-Leste Minister of Health Endorsement Letter

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Appendix E. IRB Approved Informed Consent Form

You are invited to participate in a research study under the direction of Dr. Sangeeta Mookherji and conducted by Derek Licina (DrPHc) of the Department of Global Health, George Washington University (GWU). Taking part in this research is entirely voluntary.

The purpose of this study is to inform the U.S. government and its partners of the influence U.S. Navy hospital ships have on strengthening partnerships. The U.S. Naval Ship Mercy mission to Timor-Leste during Pacific Partnership 2010 will be used as the case study. Factors impacting partnerships will be explored to develop a theoretical framework to inform future hospital ship missions.

If you choose to take part in this study, you will be asked to join us for an in-person interview. Should an in-person interview not be feasible, a telephonic interview may be conducted using this same protocol. The information you give us will be kept completely confidential, we will not report your name, nor will we report the name of the organization you work for. There are no right or wrong answers; we are only interested in learning about your experiences. The total amount of time you will spend in connection with this study is approximately 60 minutes. You may refuse to answer any of the questions and you may stop your participation in this study at any time. The interview will be audio-recorded and transcribed to maintain information accuracy.

Participating in this study poses no risks that are not ordinarily encountered in daily life. Should you experience any discomfort during the interview, please report it directly to the individual conducting the interview.

You will not benefit directly from your participation in the study. While there is no direct benefit to you, there are some important indirect benefits to current and future organizations participating in U.S. Navy hospital ship missions. Your experience as a participant in the Mercy mission provides a unique perspective for this research and we appreciate you providing your thoughts regarding this partnership.

Every effort will be made to keep your information confidential, however, this can not be guaranteed. If results of this research study are reported in journals or at scientific meetings, the people who participated in this study will not be named or identified. The results will be presented in aggregate and a copy of the final report provided to the U.S. Pacific Command in Honolulu, HI and OSD Health Affairs in Washington, D.C.

The Office of Human Research of George Washington University, at telephone number (202) 994-2715, can provide further information about your rights as a research participant. Further information regarding this study may be obtained by contacting Derek Licina (DrPH Candidate and Principal Contact for this study) at telephone number (931) 302-8609 or Dr. Sangeeta Mookherji at (202) 994-1520.

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To ensure anonymity, your signature is not required in this document. Your willingness to participate in this research study is implied if you proceed with completing the interview. Please keep a copy of this document in case you want to read it again.

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Appendix F. Timor-Leste Ministry of Health Cabinet of Health Research and Development (CHRD) Research Approval

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Appendix G. Timor-Leste Ministry of Health CHRD Informed Consent Form

Informed Consent Form

You are invited to participate in a research study looking at the impact U.S. hospital ships have on strengthening partnerships. The Naval Ship Mercy mission to Timor-Leste during in 2008 and 2010 will be used as the case study. The information you provide will be kept completely confidential. Your experience as a participant in the Mercy hospital ship mission provides a unique perspective for this research and we appreciate you providing your thoughts regarding this partnership.

Your willingness to participate in this research study is implied if you sign below.

______Signature

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Appendix H. Interview Guide for DoD Participants

Introduction

Thank you for taking the time to meet with me today. I am a third year DrPH student in the Department of Global Health at The George Washington University in Washington, D.C. and an active duty Army Medical Service Corps Officer. I am interested in learning about the impact U.S. Navy hospital ships have on strengthening partnerships. The U.S. Naval Ship Mercy mission to Timor-Leste during Pacific Partnership 2008 & 2010 will be used as the case study for this research.

The discussion in this interview is completely confidential. Your participation is completely voluntary; you may end the interview at any time; and if I ask a question that you’d prefer not to answer, just tell me and I’ll skip over it.

I’ll be asking you a series of questions and taking written notes on your responses. The interview will be audio recorded and transcribed in order to correctly and completely capture the information. I will not share the recordings or the transcriptions with anyone outside of the study team.

Do you have any questions for me before we begin?

Questions and probes

Tell me a little about your experience during the Pacific Partnership 08/10 hospital ship mission. • What did you do? Who did you work with? How long were you involved?

Keeping in mind one purpose of the hospital ship mission is to build partnerships, what does the term partnership mean to you? • Collaboration toward a common goal, sharing resources and expertise

How well did your experience fit that description?

What were the most important goals of the hospital ship partnership during PP08/10?

Based on your experience, how successful was the partnership in achieving the goals? • How did you and DoD contribute to the partnership goals?

What is holding the partnership back from achieving its goals?

How has DoD benefited from the partnership? • Improved trust, confidence, communication, commitment in non-DoD partners • Improved efficiency in delivering humanitarian assistance

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• Increased ability to achieve humanitarian assistance goals

What were the most significant successes of the partnership?

What were the most significant challenges of the partnership?

What value does the hospital ship partnership add to accomplishing the humanitarian assistance mission? • Is it the hospital ship the best resource available to accomplish the humanitarian assistance mission?

What do you think happens to the partnership when the mission ends?

Is there anything else that we ought to know about that I haven’t asked you?

Before we conclude, I’d like to obtain some background information from you that will help us characterize our key stakeholders.

Could you tell me: • Years related to humanitarian assistance work • Prior experience working on hospital ship mission • Prior experience working with interagency partners • Prior experience working with other military partner nations • Prior experience working with NGOs • Sex • Age • Profession (administrator, physician, nurse, etc)

Thank you for your time and input. You have provided us with very helpful and useful information.

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Appendix I. Interview Guide for Non-DoD Participants

Introduction

Thank you for taking the time to meet with me today. I am a third year DrPH student in the Department of Global Health at The George Washington University in Washington, D.C. and am interested in learning about the impact U.S. Navy hospital ships have on strengthening partnerships. The U.S. Naval Ship Mercy mission to Timor-Leste during Pacific Partnership 2008 and 2010 will be used as the case study for this research.

Do you have any questions for me before we begin?

Questions and probes

Tell me a little about your experience during the Pacific Partnership 08/10 hospital ship mission. • What did you do? Who did you work with? How long were you involved?

Keeping in mind one purpose of the hospital ship mission is to build partnerships, what does the term partnership mean to you? • Collaboration toward a common goal, sharing resources and expertise

How well did your experience fit that description?

What were the most important goals of the hospital ship partnership during PP08/10?

Based on your experience, how successful was the partnership in achieving the goals? • How did you and (organization) contribute to the partnership goals?

What is holding the partnership back from achieving its goals?

How has (organization) benefited from the partnership? • Improved trust, confidence, communication, commitment in DoD • Improved efficiency in delivering humanitarian assistance • Increased ability to achieve humanitarian assistance goals

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What were the most significant successes of the partnership?

What were the most significant challenges of the partnership?

What do you think happens to the partnership when the mission ends?

Is there anything else that we ought to know about that I haven’t asked you?

Before we conclude, I’d like to obtain some background information from you that will help us characterize our key stakeholders.

Could you tell me: • Years related to humanitarian assistance work • Prior experience working on hospital ship mission • Prior experience working with interagency partners • Prior experience working with other military partner nations • Prior experience working with DoD • Sex • Age • Profession (administrator, physician, nurse, etc)

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Appendix J. Thematic Codebook

Partnership Themes Definition Through Inductive Reasoning Developing relationships Developing associations between one or more hospital ship mission units of analysis Developing new New context gained during the mission by perspectives understanding another point of view Developing credibility Expertise validated by another hospital ship mission unit of analysis Sharing resources Sharing personnel, materiel, and/or finances in support of the hospital ship mission Increasing visibility Magnifying the parent organizations exposure to individuals, organizations, countries, and/or regions Generating innovation Translating a new perspective into action within the hospital ship mission Achieving Organization Accomplishing the parent organizations objectives Objectives through the hospital ship mission Developing trust Reliability gained between one or more hospital ship mission units of analysis Increasing HN capacity Increasing the ability of the HN Ministries to achieve their goals and objectives Performing new activities Performing activities not previously conducted by the parent organization Opening dialogue Starting communication between two or more hospital ship mission units of analysis Understanding partner Understanding factors that could prevent partner constraints organizations from achieving the mission goals Understanding partner Understanding items other units of analysis are trying agenda to accomplish through the mission Understanding HN needs Gaining an understanding of HN requirements ranging from the individual to national level Sharing leadership Allowing other units of analysis to assume the role of guiding and/or directing the hospital ship mission

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Appendix K . GWU Human Subjects Review Board Approval

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Appendix L. Systematic Literature Review Search Strategy and Citation Findings

Database Search Date Years Search Term Strategy (Descriptors, free text, related descriptors) Citations (mm/dd/yr) Covered CENTRAL 04/04/12 2004- 1 "usns mercy".mp. [mp=title, original title, abstract, mesh headings, heading words, keyword] 3 present 2 "usns comfort".mp. [mp=title, original title, abstract, mesh headings, heading words, keyword] 3 "hospital ship mercy".mp. [mp=title, original title, abstract, mesh headings, heading words, keyword] 4 "hospital ship comfort".mp. [mp=title, original title, abstract, mesh headings, heading words, keyword] 5 "navy medical ship".mp. [mp=title, original title, abstract, mesh headings, heading words, keyword] 6 "hospital ship".mp. [mp=title, original title, abstract, mesh headings, heading words, keyword] 7 "medical ship".mp. [mp=title, original title, abstract, mesh headings, heading words, keyword] 8 "pacific partnership".mp. [mp=title, original title, abstract, mesh headings, heading words, keyword] 9 "continuing promise".mp. [mp=title, original title, abstract, mesh headings, heading words, keyword] 10 "naval medicine".mp. [mp=title, original title, abstract, mesh headings, heading words, keyword] 11 "military medicine".mp. [mp=title, original title, abstract, mesh headings, heading words, keyword] 12 "ships".mp. [mp=title, original title, abstract, mesh headings, heading words, keyword] 13 10 or 11 14 12 and 13 15 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 14 16 limit 15 to yr="2004 -Current" MEDLINE 04/04/12 2004- 1 "usns mercy".mp. 236 present 2 "usns comfort".mp. 3 "hospital ship mercy".mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier] 4 "hospital ship comfort".mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier] 5 "navy medical ship".mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier] 6 "hospital ship".mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier] 7 "medical ship".mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier] 8 "pacific partnership".mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]

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Database Search Date Years Search Term Strategy (Descriptors, free text, related descriptors) Citations (mm/dd/yr) Covered 9 "continuing promise".mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier] 10 "naval medicine".mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier] 11 "military medicine".mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier] 12 "ships".mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier] 13 10 or 11 14 12 and 13 15 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 14 16 limit 15 to yr="2004 -Current" Military & 04/04/12 2004- "navy medical ship" OR "usns mercy" OR "usns comfort" OR 193 Government present "hospital ship mercy" OR "hospital ship comfort" OR "hospital Collection ship" OR "medical ship" OR "pacific partnership" OR "continuing promise" PAIS 04/04/12 2004- all("navy medical ship") OR all(("usns mercy" OR "usns comfort")) OR all(("hospital ship mercy" OR 14 International present "hospital ship comfort")) OR all(("hospital ship" OR "medical ship")) OR all(("pacific partnership" OR "continuing promise")) ProQuest 04/04/12 2004- "navy medical ship" OR ("usns mercy" OR "usns comfort") OR ("hospital ship mercy" OR "hospital 221 Dissertation present ship comfort") OR ("hospital ship" OR "medical ship") OR ("pacific partnership" OR "continuing and Theses promise") PubMed 04/03/12 2004- ((((((((("USNS Mercy"[All Fields] OR "USNS Comfort"[All Fields]) OR (("hospitals"[MeSH Terms] 569 present OR "hospitals"[All Fields] OR "hospital"[All Fields]) AND ("ships"[MeSH Terms] OR "ships"[All Fields] OR "ship"[All Fields]) AND mercy[All Fields])) OR (("hospitals"[MeSH Terms] OR "hospitals"[All Fields] OR "hospital"[All Fields]) AND ("ships"[MeSH Terms] OR "ships"[All Fields] OR "ship"[All Fields]) AND comfort[All Fields])) OR (navy[All Fields] AND medical[All Fields] AND ("ships"[MeSH Terms] OR "ships"[All Fields] OR "ship"[All Fields]))) OR "hospital ship"[All Fields]) OR (medical[All Fields] AND ("ships"[MeSH Terms] OR "ships"[All Fields] OR "ship"[All Fields]))) OR (pacific[All Fields] AND partnership[All Fields])) OR "continuing promise"[All Fields])) AND ("2004"[Date - Publication]: "2012"[Date - Publication]) Scopus 04/04/12 2004- TITLE-ABS-KEY ("navy medical ship" OR "usns mercy" OR "usns comfort" OR "hospital ship 141 present mercy" OR "hospital ship comfort" OR "hospital ship" OR "medical ship" OR "pacific partnership" OR "continuing promise") AND PUBYEAR > 2003

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Database Search Date Years Search Term Strategy (Descriptors, free text, related descriptors) Citations (mm/dd/yr) Covered Thomson 04/04/12 2004- Topic=("usns mercy") OR Topic=("usns comfort") OR Topic=("hospital ship mercy") OR 68 Reuters present Topic=("navy medical ship") OR Topic=("hospital ship") OR Topic=("medical ship") OR (formerly Topic=("pacific partnership") OR Topic=("continuing promise") OR Topic=("hospital ship comfort") ISI) Web of Timespan=2004-2012 Knowledge

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Appendix M. Sources Excluded After Systematic Review Eligibility Assessment

Title Year Publication First Author Reason for Exclusion

Navy nurses' experiences during Operation 2007 Dissertation Almonte, A. Basis of Military Medicine Journal Article which met Unified Assistance aboard the USNS inclusion criteria, duplicate MERCY: A grounded theory study

The rise of Chinese military medicine: 2011 Journal: Chambers, J. Mercy ship is but 1 recommended tool for increasing opportunity for mercy ship, not gunboat, Military diplomacy between the countries, not the focus of the diplomacy Medicine article Complexity in disasters: A case study of the 2011 Dissertation Conner, D. The author of this dissertation has placed it under Haitian earthquake response embargo until 01/01/2013

The U.S. Navy surface force's necessary 2011 Thesis Bergeron, P. Extends beyond the scope of Navy hospital ships capabilities and force structure for humanitarian assistance and disaster relief (HA/DR) operations

'We are here to help': comfort story No. 1 2006 Journal: Health Braner, D. A 9 sentence short story of USNS Comfort experience Affairs We are here to help': comfort story No. 2 2006 Journal: Health Conlin, J. A 12 sentence short story of a USNS Comfort Affairs experience Concurrent outbreak of norovirus genotype I 2011 PLoS One Gonzaga, V. Article did not name the Navy ship from which this and enterotoxigenic Escherichia coli on a study originated U.S. Navy ship following a visit to Lima, Peru Band of crusaders: American humanitarians, 2009 Dissertation Little, J. Focus on America's rise to international power the Great War, and the remaking of the world between 1912 and 1924

Vessels of mercy 2010 Annals of Louwrens, N. Letter to the Editor focused primarily on the NGO Internal Mercy Ships Medicine

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Title Year Publication First Author Reason for Exclusion

Combined Support Force 536: Operation 2006 Military McCarntney, S. Not specifically related to hospital ship missions, Unified Assistance Medicine rather a collective overview of medical support providedby CSF 536 during the tsunami relief effort

Challenges of military nursing: come on 2005 Nursing Morro, M. Focus on USNS Comfort during OIF 2003 (prior to board hospital ship COMFORT 2004 inclusion criteria)

The role of a dermatologist on military 2010 Cutis Satter, E. Focus on dermatology in support of HA missions, not humanitarian missions hospital ship specific Keynote address: the humanity of 2009 Journal of Bone Sechriest, V. Limited 2 paragraph discussion of topic as it relates to orthopaedics and Joint HA and hospital ship missions Surgery Has the Red Cross adorned hospital ship 2005 Naval War Smith, A. Focus on hospital ship immunity and security with become obsolete? College Review historical context. Does not deal with HA/DR from 2004 to present. Air Force disaster response: Haiti experience 2011 Journal of Stuart, J. Although the USNS Comfort was mentioned, the surgical primary focus is to highlight unique Air Force orthopaedic medical capabilities deployed to Haiti. advances Asian tsunami relief: Department of Defense 2006 Military Tarantino, D. The USNS Mercy is mentioned; however, the primary public health response: policy and strategic Medicine thrust of this article is the policy and strategic coordination considerations coordination process Laparoscopy at sea: overcoming unique 2004 Bulletin of the Thoman, D. Focus on medical support provided on Navy vessels challenges American other than hospital ships College of Surgeons An Assessment of Navy Medicine's 2012 Dissertation Wolfe, H. Extends beyond the scope of Navy hospital ships Homeland Defense, Emergency Preparedness, Civil Support and Humanitarian Assistance Disaster Response Capabilities

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Title Year Publication First Author Reason for Exclusion

Massachusetts General Hospital Participation 2006 Military Waichi, W. Duplication, last name miscoded in this database pull in Operation Unified Assistance for Tsunami Medicine Relief in Banda Aceh, Indonesia

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Appendix N. Sources Included After Systematic Review Eligibility Assessment

Title Year Journal First Author Coding per Country of Outcome measured Appendix H Study Setting Humanitarian nursing challenges: a 2009 Military Medicine Almonte, A. 1,4,1,2,2,3,1,2,6 United States Navy Nurse Experiences grounded theory study during Tsunami response Practicing Internal Medicine 2010 Annals of Internal Amundson, D. 1,1,1,2,2,4,2,4,9 Haiti Mission description Onboard the USNS COMFORT in Medicine the Aftermath of the Haitian Earthquake Charting a course into the unknown: 2007 Perspectives in Anderson, K. 1,1,2,6,2,3,2,4,9 Indonesia Mission description Banda Aceh, Indonesia, tsunami, Psychiatric Care 2004 Mercy Mission 2006 Sea Power Atkinson, P. 1,1,1,2,1,2,2,5,9 Pacific Mission description Region USNS comfort: caring for the sick at 2008 International Bailey, P. 1,1,1,2,3,6,2,5,9 Pacific and Mission description sea Anesthesia Caribbean Research Society Regions Just-in-time mental health training 2006 Military Medicine Benedek, D. 1,1,1,2,2,3,1,1,2 United States Mental health training and and surveillance for the Project outcomes (pre/post without HOPE mission. statistical significance due to small sample size) Pacific Partnership 2008: U.S. Navy 2009 Bulletin of the Davis, K. 1,1,1,2,1,1,2,4,9 Pacific Mission description Fellows provide humanitarian American College Region assistance in Southeast Asia of Surgeons During Haiti Mission, USNS 2010 Sea Power Eisman, D. 1,1,1,2,2,4,2,4,9 Haiti Mission description Comfort Crew Saddened, Sobered, Inspired and Proud Disaster relief in Haiti: a perspective 2010 Lancet Neurology Etienne, M. 1,1,1,2,2,4,2,4,9 Haiti Mission description from the neurologists on the USNS COMFORT

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Title Year Journal First Author Coding per Country of Outcome measured Appendix H Study Setting

Healthcare ethics: the experience 2010 American journal Etienne, M. 1,1,1,2,2,4,6,4,9 Haiti Mission description after the Haitian earthquake. of disaster medicine Radiology afloat: The impact of 2009 Journal of vascular Farrar, S. 1,1,1,2,2,3,2,4,9 Pacific Mission description diagnostic and interventional and interventional Region radiology during the 2005 tsunami radiology relief effort aboard the USNS Mercy Airway management of tetanus after 2011 Anesthesia and Firth, P. 1,1,2,1,2,4,2,4,9 Haiti Airway management of the Haitian earthquake: new aspects analgesia Tetanus victim of old observations Anesthesia services during operation 2007 Military Medicine Fitzsimons, M. 1,1,2,1,2,3,2,4,9 Pacific Mission description unified assistance, aboard the USNS Region Mercy, after the tsunami in Southeast Asia Dermatology aboard the USNS 2011 Dermatologic Galeckas, K. 1,1,1,2,2,4,2,4,9 Haiti Mission description COMFORT: Disaster relief clinics operations in Haiti after the 2010 earthquake Utilization of surgical resources 2010 Military Medicine Hartgerink, B. 1,1,1,2,1,1,2,1,2 LAC Region Resource Utilization during the USNS COMFORT humanitarian mission to the Americas, June to October 2007 The 2010 Haiti earthquake: a 2011 Archives of Hussey, S. 1,1,1,2,2,4,2,4,9 Haiti Mission description pathology perspective aboard the pathology & USNS Comfort. laboratory medicine Pacific Partnership 2008: the 2010 Military Medicine King, H. 1,1,1,2,1,2,2,4,9 Pacific Mission description surgical mission, surgical screening Region process, and the anesthetic management of uncontrolled, untreated hypertensive patients

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Title Year Journal First Author Coding per Country of Outcome measured Appendix H Study Setting Good Will Cruisin' 2009 The Officer Kouhestani, J. 1,1,2,6,1,2,5,5,9 Pacific Mission description Region Perspectives from MTF USNS 2006 Military Medicine Llewellyn, M. 1,1,1,2,2,3,2,4,9 Pacific Mission description Mercy Region Hope on the Horizon 2006 All Hands McCoy, S. 1,1,1,2,1,2,2,4,9 Pacific Mission description Region Lessons learned from Indonesia: an 2006 Military Medicine McDaniel, W. 1,1,1,2,2,3,2,4,9 Pacific Mission description and outline Region lessons learned The USNS Mercy and the changing 2006 Military Medicine McGuinness, 1,1,2,1,2,3,2,4,9 Pacific Mission description and landscape of humanitarian and K. Region physcological isses for disaster response responders Tsunami overview 2006 Military Medicine Morrow, R. 1,1,1,2,2,3,2,4,9 Pacific Mission description Region Determining medical staffing 2010 Military Medicine Negus, T. 1,1,1,2,3,6,2,1,2 Pacific Hospital ship staffing requirements for humanitarian Region requirements assistance missions The Project HOPE and USNS Mercy 2006 Military Medicine Peake, J. 1,1,2,6,2,3,5,4,9 Pacific Mission description tsunami "experiment" Region Operation Unified Assistance 2006 Military Medicine Perez, J. 1,1,1,1,2,3,2,4,9 Pacific Mission description and population-based programs of the Region behavioral health U.S. Public Health Service and interventions international team Humanitarian assistance and disaster 2011 Journal of surgical Provencher, 1,1,1,2,1,2,2,4,9 Pacific Mission description relief aboard the USNS Mercy orthopaedic M. Region (TAH-19) advances Health diplomacy through 2006 Military Medicine Pryor, T. 1,1,1,1,2,3,2,4,9 Indonesia Mission description collaboration and a story of hope in tsunami-ravaged Banda Aceh, Indonesia: A U.S. Public Health Service nurse officer perspective

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Title Year Journal First Author Coding per Country of Outcome measured Appendix H Study Setting Treatment of earthquake-related 2010 Plastic and Ray, J. 1,1,1,2,2,4,2,1,2 Haiti Craniofacial injuries craniofacial injuries aboard the reconstructive USNS Comfort during Operation surgery Unified Response The virtual network supporting the 2006 Military Medicine Reissman, D. 1,1,1,1,2,3,2,4,9 Pacific Mission description front lines: addressing emerging Region behavioral health problems following the tsunami of 2004 The role of a dermatologist on 2010 Cutis Satter, E. 1,1,1,2,1,6,2,4,9 Pacific and Mission description military humanitarian missions LAC regions Prolonged femoral external fixation 2008 American journal Sechriest, V. 1,1,1,2,2,3,2,4,8 Indonesia Single femoral fixation case after natural disaster: successful late of disaster description conversion to intramedullary nail medicine aboard the USNS Mercy hospital ship Pacific Partnership 2010: 2010 Journal of the Skyrme, L. 2,1,1,2,1,2,2,4,9 Pacific Mission description humanitarian civic assistance on a Royal Naval Region U.S. Navy hospital ship Medical Service Pacific Partnership: a U.S. Navy 2010 Bulletin of the Tadlock, M. 1,1,1,2,1,2,2,4,9 Pacific Mission description resident's experience on the USNS American College Region Mercy in Southeast Asia of Surgeons Making a difference: CRNAs aboard 2010 AANA Journal Thomas, S. 1,1,1,2,2,4,2,5,9 Haiti Mission description the USNS Comfort respond to the disaster in Haiti Project HOPE volunteers and the 2006 Military Medicine Timboe, H. 1,1,2,1,2,3,5,4,9 Pacific Mission description Navy Hospital Ship Mercy Region

The USNS Mercy's Southeast Asia 2007 AORN Journal Troup, L. 1,1,1,2,1,2,2,4,9 Pacific Mission description humanitarian cruise: the Region perioperative experience

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Title Year Journal First Author Coding per Country of Outcome measured Appendix H Study Setting

Three phases of disaster relief in 2011 Journal of pediatric Walk, R. 1,1,1,2,2,4,2,1,2 Haiti Pediatric surgical patients Haiti--pediatric surgical care on surgery board the United States Naval Ship Comfort Strategy at the crossroads: Medical 2010 Defense and Webb, N. 1,1,1,2,3,6,6,5,9 None Hospital ship utilization humanitarian assistance missions for security analysis policy navy hospital ships Bringing comfort to Haiti 2010 Plastic surgical Wegner, R. 1,1,2,1,2,4,2,4,9 Haiti Mission description nursing Delivering Hope 2010 Sea Power Whittman, A. 1,1,1,6,2,4,2,5,9 Haiti Mission description Massachusetts General Hospital 2006 Military Medicine Wong, W 1,1,2,1,2,3,5,4,9 Pacific Mission description Participation in Operation Unified Region Assistance for Tsunami Relief in Banda Aceh, Indonesia Medical-surgical nurses volunteer to 2005 Medsurg Nursing Yates, M. 1,1,1,2,2,3,2,4,9 Pacific Mission description aid tsunami victims Region

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Appendix O. Perceived Goals by Unit of Analysis

Organization Representative Quotes

USG

Goal “Unfortunately, I don’t know what all the goals were. I think for the immediate, the clearest and fastest targets were actual services provided” “I really don’t recall to be honest” “I suppose the goals were to show the Timorese that we care about their issues and to work on trying to mitigate or fix some of them, but I don’t really know” “there was a foreign policy element to it, about building relationships…where the mission visited” “The larger picture, obviously, is part of the whole Theater Security Cooperation for PACOM and from PACFLT that we want to go ahead and establish long-term relationships in the area” “a huge part of the mission is just when we put hundreds of American and partner nation people through the country, it just builds a lot of goodwill and support among the population when they see us, you know, MEDCAPs, showing compassion, empathy, and things like that” “to build partnerships, to build capacity in the hose nation, and to train and prepare better for future disaster response in the region, all with the goal of just building stability and stability is certainly good for U.S. interests in that region” “promote pacific region development, relationships, strength, and disaster preparedness through public diplomacy and partnerships” and “they really want to show that okay, this partnership is working” “maintaining a humanitarian assistance and disaster relief capacity on the part of the DoD and its partner organizations” “The mission in general is designed to increase everybody’s ability to respond to disasters because each one of these countries has disasters. The partners who send people to our ship, they have disasters. We have disasters. So getting an appreciation of how disaster response can work and how you can partner with NGOs is really important” “the main goal of the mission is to help build capacity in the countries” “showing how confident the NGOs here are to help and assist the government, but also showing the commitment of all the countries that assist the Timorese is probably the most important thing” “build the relationships with ourselves and the different NGOs, build the relationships with the host nation and the NGOs, and also to help the host nation in their relationship with their own civilian population” “to strengthen host country capacity in the health sector” “it’s capacity building and it’s a strong focus on disaster response in the future but then using current missions just to kind of practice, to learn” “to address the needs that is beyond the capacity of the country” “the delivery of humanitarian services, medical services, but then also the development of, or strengthening of the working

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relationship that existed between our two militaries.” “deliver humanitarian assistance and medical services, but my understanding all along was that was definitely a tertiary goal” “in general, it was to help build infrastructure in the country, medical infrastructure” Achievement “very high level it didn’t seem to have too much change there” “for healthcare you have to come back multiple times over a few years working on the same project to really build capacity where you develop people, as you know, and in medical education it takes years of training and we go in and we have this idea that in just a two week visit we’re going to build capacity. That’s really a hard thing to demonstrate.” “I think PACFLT, the line side, is looking for these big, gigantic gains from these two-week missions and I don’t think we’re ever going to see that” “I would have to say very successful, just simply looking at the numbers of treatments that they can’t get on the island and just the shear volume of people that were treated” “Profoundly. I think out of my three years of service in Timor-Leste the greatest display of U.S. commitment to Timor-Leste was manifested through the visit of the Mercy…Just the impact that we had on showing the flag and showing that Americans cared to the average citizen of Timor-Leste, including in some very remote areas of the country, was exceptional, it exceeded my expectations.” “on the big, high level, when you do it on a regular basis, I think it builds a working partnership pretty effectively” “I didn’t hear anything afterwards. I certainly didn’t receive any feedback from it” Partner Nation

Goal “to learn about how other countries worked” “I’m guessing it is really to foster the relationships between the host country and the U.S. and also the partnerships to have that close working relationship” “I know there’s an ulterior thing here as well, about the global war on terror and force projection and the mitigation against Chinese expansion in the Asia-Pacific area…while all that goes on, we were purely focused on humanitarian and partnership building in that area” “to enhance the partnership in that region…the provision of humanitarian type assistance…to build capacity within host nations that they did not have and to meet ongoing global engagement strategies, and to enhance security in the region” “trying to deliver as much good care as we could to the locals” “to work together to provide as much treatment or care, services to the locals as we could” “Truthfully, I can’t remember” and “No, it was too long ago” Achievement “I think they were very successful” “I thought we were very successful. It was awesome” “I think that the surgeons, dentists, ophthalmology, the physios did a splendid job and could see their results” “We got to spend a lot of time with them and yeah, so it was a good partnership between us all because obviously we have the same goal in providing that care and treatment for the locals” “These hospital ships could, you know, anchor and be there for a couple of years and still not see everybody, do everything” Host Nation

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Goal “The main purpose is to provide the assistance to the people.” “I think the most important goal is to actually help contribute to service delivery in Timor-Leste…filling some of the gaps that the government experience in Timor-Leste.” “the objective of the partnership to complement the government service because we know Timor-Leste is a new country.” “medical, yeah, medical assistance.” “In 2010 for the mission, there’s just not one focus on humanitarian service or healthcare, but the important also they provide training to our national people, that’s important” Achievement “I think it’s successful” “for sure they achieved it” NGO

Goal “to increase better relationships with the countries we visited and give a picture of the United States of America as not being the big evil giant.” “I think it’s PR. I think it’s the soft diplomacy type of things” “it was all Navy specified, which was diplomatic door opening, showing the flag, training of DoD personnel with the indigenous military personnel counterparts” “the goal I was told that we would be performing was building relationships and also, so if there was a natural disaster or a concern that country had a natural disaster or a problem in the country, then they would have better relationships with the U.S. and obviously non-government organizations so that we could help them better in the future.” “if you look at really kind of when the DOD presents these and they’re very honest about it, it says, these are training missions, number one. I think the partnerships and the kind of inter-operability training and that sort of thing is there with that or maybe even second and farther down the line, and, it’s like I said, it’s clearly stated but I think somewhat farther down the line is that help support the beneficiaries, which tends to be a little bit lower down the chain, and for volunteers that don’t understand the concepts of the medical diplomacy and the relationship building and that sort of thing, when they’re there just to help sometimes you got to really manage that expectation.” “the stated goal is to strengthen regional alliances, build capabilities, to respond to crisis basically…there’s also humanitarian objectives which is to improve the health of these people and these populations, but to tell you the truth, I mean, it’s like spitting in the ocean.” “the mission to support the government, support the Ministry of Health, to fill the gap, and to ensure that better health for the Timorese nation” “their presence was to support the Ministry of Health to see some patients from very remote places that they never access to hospital for medical treatment” Achievement “No idea to be honest because I think that’s probably more a diplomatic and political” “if you’re looking for objective measures, I’m not sure, I don’t know if I could come up with any.” “I don’t know that we get feedback on that success or failure.” “I think the international public health outcomes are probably very, very limited.” “There’s always conversation that we’re, it’s a partnership and we’re partners but, you know, in the play-out it’s not really been the

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case.” “I think it was very, pretty effective. It was definitely good door-opening. We saw tons of patients, did lots of surgeries, handed out lots of pharmaceuticals, pulled lots of teeth, issued lots of eyeglasses, but did it improve the, by any U.N., WHO, World Health, U.S. public health standards of measurement and effectiveness, did we improve the health? I don’t, nobody can say and numbers of patients seen has nothing to, has no correlation to improving the health. The fact is we only treated acute presentations, didn’t treat any chronic disease.” “Successful, obviously, I can say that yes, it’s successful because they provided treatment…but in terms of sustainability, so I think it would be nice if there would be some follow up and phase out strategy.” “I think the training aspects do go very well and I think the inter-operability, the partnership development within the United States, i.e., the DOD, inter-agencies, NGOs, the folks that are deploying abroad, I think that interface goes very well.” “I can say that in terms of the coordination, collaboration that time very successful” and “I think so because those clients that referred to them, they were very happy.”

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Appendix P. Partnership Definition by Unit of Analysis

Organization Representative Quotes

USG

Definition “two separate entities working towards a mutual goal or goals” “a willingness for organizations to work together for a common goal. Maybe this, the common goal isn’t always a direct part of their own mission but supports their missions.” “a partnership to me means working together with another entity, strategizing, thinking about goals and outcomes, thinking about methodology together and coming up with joint ways of trying to do things.” “it’s any sort of a situation where you’re working together in a equal standing, not in a case where we’re not instructing their personnel.” “Partnership means harvesting the different parties that could be involved in a specific purpose or meeting a specific objective and coming to a common agreement on how they would work together and share resources, share knowledge and expertise and work those in harmony and union to meet the objective “I define it as a relationship between people in the lowest level and at countries at the highest level of where you begin to work together, you know each other, you can come to rely on each other.” Achievement “There wasn’t a sense of necessarily thinking about any sort of sustainable partnership over the time. It was purely to serve a purpose, to get the job done, and I think given that it was the sort of in-out, once the job’s done, people walk away and then the people that they were sort of trying to serve, which is the community and through the Ministry of Health, they don’t receive any feedback after the task is done. So from my sense, it serves more the purpose of the people who are coming in and not necessarily the objective that it’s supposed to achieve in sustaining a sort of a partnership that the Ministry feels that they can rely on in the future.” “Well, I really don’t know but I can tell you what I think. I think the military is great. They really want to do the right thing but this in-and-out doesn’t really lead to anything and there’s a, a naïve but wonderful view by the military, in other words, they gathered all these NGOs and they had charts and Power Points and they said, “You’ll do this and we’ll do that,” but it’s one shot. They come and they have their meeting and they expect people to be there and people are and they have a good interchange but then after that, it’s really hard to follow up so I’m not sure if anything came of it. Maybe there is but I’m not aware of it.” “It’s such a short period of time that it cannot serve as a partnership because it’s not ongoing but what it does do is, I think, de- legitimize the service that the Ministry of Health is trying to do.” “For this country it’s just increasing the capabilities. It’d be a long way from a partnership only because they’re still in the crawl phase.” “working at like a national level or operational level it probably didn’t change very much but a lot of the experience came from out there in the field.” Another stated, “I know the goal of the developing familiarity between the out in, you know, in the deck plate level, our personnel and their medics or engineers and their local clinic personnel, I think it was very, very successful at that level. And what it did for public perception I don’t know.”

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“I think, and it’s not just personal pride, I would say it did very well at that.” “it did it very, very well. So, for example, my staff got to know that host nation staff and so even after the ship had sailed away, there was still e-mail communication going on and professional friendships.” ““Oh, yes, we tried to really link up the last Pacific Partnership with the NGOs and try to show the Minister of Health, “Hey, all these NGOs are here that have different capabilities. If you bring them in and bring the military in with it, you can do these med-caps yourself by pooling your resources.”” “I think the 2010 mission built new partnerships and improved existing partnerships. If the goal is simply partnership, I think it did a very good job, but I would suggest that possibly the ship visits aren’t just for building partnerships.” Partner Nation

Definition “a partnership is where people contribute equally and both feel that they’re equally valued and that you’re getting something for it as well.” “partnership, to me, would mean having equal footing, equal standing amongst all key stakeholders around the table and actively being a participant in the planning and getting the mission ongoing.” “partnership is working equally alongside somebody else to do something.” “I think the partnership brings to mind that you’re equal. You’re putting in equal input into something by putting equal amounts of effort and work into something, is what you say is a partnership.” “the partnership would be sort of working together as a team to meet some sort of common objective and to sort of share ideas.” “to work together to be able to provide that humanitarian mission to wherever we happen to be.” “it’s a commitment to each other. It’s that sustained relationship over time and it’s that mutual support. It’s the building and strengthening of relationships.” Achievement “I don’t think it fits the definition very well. I don’t view we were a partner in the mission. I believe we were shipped as just simply participants and our job was to not have any impact on the execution of the mission, just simply ride the mission out and provide a capability that the U.S. Navy or other DOD organization couldn’t do it. We did not have any impact on any part of the execution of the mission.” ““I found that as a partner nation we were not a key player around the table. We were sort of, you know, “Well, what do you think about this?” but not really, you know we as a nation, view this as, “Look, we’re going to cooperate with the Americans. We’re going to help them fill some bills that they cannot fill but the bottom line is it’s their show.” So we were, even though we were a full partner in the partnership sphere, we were a minor player in the overall operation, and my experience was that regardless the U.S. Navy and the planners on that side would do whatever their chain of command wanted them to do regardless of input from other partners.”” “ I don’t think it could be an equal partnership, you know. This is driven by the U.S.. The U.S. is funding the mission. They’re providing the platform. They’re providing, you know, the rations and quarters, the O&M for the ship. So ultimately, the U.S. Navy is in charge.” “exceptionally well” “it was fabulous, we were taken in right away as part of the team.” “Well, I guess, in 2008 we felt like a small contingent, like a small part of a bigger partnership. It very much was an American-run operation but you did feel that you were contributing very much so. I think the feeling I got with the (partner nation name deleted)

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were they were very much valued in this partnership. They saw the (partner nation name deleted) as people who want to have a go and who want to work hard and who always want to seem to be contributing. So I felt that we were a good part of this partnership, but a smaller part.” Host Nation

Definition “the interaction between two parties through mutual understanding with the same purposes. What I say, mutual understanding it means that we understand all differences, different difficulties, different technologies, different skills that we have, but we try to work out all of this, and with the mutual trust.” “partnership is, for my opinion, is, you know, it’s improve the understanding each other.” “sharing knowledge, skills, experience, learning from each other and, yeah, it’s partnering, sharing knowledge and information between different groups or different people, two people. In this case, between the mission and Timor-Leste health professionals “the partnership is collaboration, work together between President, the Minister of Health, the government, and other agencies or NGOs.” “a partnership is not only mean that we go together or we sit together but the important thing is how we can have the same commitment and then also the same vision, where we start and where we go. That’s the important part.” Achievement “it was very successful.” “it was actually very successful in the sense that everybody was involved and excited as well, and even the population were excited because the media got involved.” “successful, from my personal vision because those activities that we organize in the district and in sub-district runs very well and also the community, they have the opportunity to receive the humanitarian service and also accommodate those needs that community need and also the important is how the community got the positive response to the mission.” “we talk about partnership and like something lose in the partnership side, so we go mostly to the humanitarian.” NGO

Definition “Working together as a team” “partnership to me means like a, it’s 50/50 if it’s two partners, if it’s three, it’s 33 each. It’s give and take. We do something in return for you doing something else. It’s us, it’s one partner contributing the piece of the pie that’s missing.” “It’s a two-way process. It’s working together to achieve something, though, in this instance it was to build better relationships and I believe, well, I was under the impression that we were going out to these countries to build relationships and share information.” “a collaboration, a identifying, I guess, in some ways the strengths and weaknesses of different parties and bringing those together and seeing, trying to find, I guess, the best ways to find, to have those offset and the way I look at it is when I look at these development programs that we do, is we do have areas that we’re good at and things that we need support with and then if we can find partners that also have similar needs but on the opposite end, so that our strengths are things they need and vice versa. I think it works out very well, and having more of an equality in a partnership, I think, is important.” “there’s all different levels of partnership…working in conjunction with other organizations, countries, trading each other our knowledge and teaching each other and working together as a group to, for a common purpose, a common goal.” “What it means to me is that we have mutual exchange of ideas and understanding of each other’s needs and some input from, some

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input which engenders a response on behalf of all parties, some agreements and not just being told.” Achievement “it was very good partnership because it involve so many people, so many organizations during the presence of the U.S. Mercy ship in Dili. And different people, different organizations doing different roles, so that was the good things to work together.” “just at the ground level, provider standpoint, you could see pieces where this partnership was benefiting.” “Yeah, I think it did. I think we provided a lot of short-term solutions but not many long.” “I can’t see any partnerships because I would’ve thought the partnership is of lasting duration, sustainable, and I don’t think that coming once every two years or so with different people usually is a real partnership.” “I would say based on my definition there, I don’t think we, that was achieved. Better integration would have felt like a partnership and it would’ve felt like it’s reasonable in a sense for the responsibility of follow-up are to be born by the Ministry of the existing system and partners within that system. But you’d need it to feel like a partnership from the very beginning and shared, not shared ownership, ownership is the wrong word, shared responsibility.” “I think it’s difficult to share, to have a true partnership when there’s very different standards from the beginning…I think because we obviously have a much higher standard of care in (country name deleted) and in the (country name deleted), it’s very difficult if they haven’t got the equipment that we have. So I think, you know, their hospitals aren’t nearly as equipped as ours and they don’t have the medical provisions that we have. So it’s difficult to have a very true partnership.”

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Appendix Q. Theme: Developing Relationships

Key Findings Summarized

This theme was the most prominent of all 15 themes identified during the key stakeholder interviews. Developing relationships is a plausible element of building connections as depicted in the theoretical framework (Figure 7) and featured in all key stakeholder interviews, within all units of analysis, and across all levels of participation. Among the 164 references coded, operational participants (42.4%) most often cited this theme followed by tactical (37.2%) and strategic level (20.4%) participants. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of developing relationships. The theme was triangulated during the documentary review where developing relationships featured in 3 (60%) of policy, 10 (83%) of guidance, and 3 (60%) of planning/execution documents reviewed.

Evidence from Interviews

Within Units of Analysis

USG: Military

Relationship building was a common theme among military participants, especially military-to-military relationships. One participant with robust hospital ship experience stated, “we definitely benefited from the coordination with the F-FDTL. So any future events we have more of a working relationship, not only with the leadership of the F- FDTL, which I think we already had a relationship with them, but more of a relationship with these guys who are the junior enlisted who are out there in the field, junior officers, who will become the field grade officers, the Senior NCOs of the future.” They went on to highlight the impact these relationships would have by stating, “I think it’s very good to have all these partner nations see the hospital ship, to live on the hospital ship so they know the capabilities because who knows where the next disaster or anything like that will be in, and even though the people that some of these countries send are very junior, like I said before, ten years from now they’ll be senior leadership. So I really think fostering long-term relations, I think that’s under-acknowledged on the year-to-year reviews of these programs is the fact that the people we’re working with now are going to be the leadership ten or fifteen years from now.” The mission was also effective in developing relationships between nations with historical adversarial relationships. One participant noted, “In 2008 I know we had the Indonesians with us when we were in Timor-Leste and it was kind of, we were just to build those relations and to help in many ways, it promotes regional stability with the Timor-Leste working with Indonesian physicians aboard our ship and staying, and helping out and caring, I think just kind of helps promote a little stability in the region, given the history.” Acknowledging the limited duration of the hospital ship mission, one participant claimed relationships are still fostered with personnel working in the HN when they stated, “Even though it’s a

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limited visit, at least if you get a couple of weeks on the ground, you can establish relationships, as we did with the embassy there, relationships with some of the other organizations.”

USG: Non-Military

According to non-military participants, relationships were developed among the hospital ship partners as well as with the host nation population. A senior level participant stated, “the relationship between the U.S. military and the Timor-Leste military, I’d say probably in terms of all the partnerships, that’s probably one of the most significant ones that the mission contributed to.” In terms of other partners, they went on to say, “With the Australians, it was certainly a good opportunity to exercise together but I don’t think it substantially changed the relationship, it certainly didn’t hurt it. I wouldn’t say it substantially improved it. In terms of the host government, I would say it improved it.” An operational level participant also described the impact hospital ship missions have on developing relationships with the HN population. They stated, “I know that your partnerships are restricted to governments and organizations, but I think we’re very fortunate here in Timor that the view of the population in general is very favourably disposed to the U.S., and in a sense the ship visits build a partnership with the public, with the people of Timor-Leste. It’s very hard to measure.”

PN: Pacific Region Presence

The partner nation military with a regional presence felt a common mission (e.g. providing HA) and dissemination of daily mission accomplishments helped develop relationship between the various partners. Recurring missions with continuity among the participants further developed initial relationships at the individual and organization level. One tactical level participant stated, “they were all there to do the one job and they knew what the job was and they all just worked together and the camaraderie was amazing and doing that is fantastic because then what happens is you build relationships.” They went on to say, “Every day they would say this is how many people we’ve seen today and da-da-da. So that was actually really good, keeping everybody up to date every day was fantastic. Everybody really enjoyed that and I think that really helped cement peoples’ relationships and make people think, feel they were a part of something.” A participant with the experience of multiple hospital ship missions stated, ““I would think that we have a much better working relationship now with definitely the U.S. Navy. That’s just myself as a lieutenant but higher up, I think we have a lot better working relationship… So the good thing about 2008 is when I went onboard and went into the operating theaters, again, there were two people that I knew before, so that was fabulous and there were two nurses. We got to renew our friendship again and that was really nice and they said to me, “Well, you’re a bit of an old hand here, aren’t you?”” Upon redeployment, they would “come back and tell people about our trip and, you know, we spent time with the Americans and with the Canadians and with the Indonesians and that’s how I’d say it’s positive and just strengthens those relations because we have served with them, so to speak.”

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PN: Non-Regional Presence

From an organization level, the partner nation military participants nurtured existing relationships with the U.S. military and developed new relationships with all the other hospital ship mission participants to include NGOs and partner nation militaries. A senior participant with multiple mission experience stated, “I was able to make great connections and have links into various planning levels in the U.S.. So I was very fortunate in the sense that I had the continuity and I had the links already in the various headquarters… our strongest partner nation is the U.S. Navy by far. If it wasn’t for our relationship with your organization, you know, DOD and the U.S. Navy and all other organizations in your military, we wouldn’t be participating…they’ve reached out to enormous nongovernmental organizations and I’ve seen that firsthand with the amount of NGOs that have now come forward to want to be part of these exercises and to actively put volunteers on it and not only human volunteers but gifts and resources and supply. I’ve also seen the U.S. Navy reach out to mil-to-mil partners in the region, Australia, New Zealand, Japan, these are just some of the partners that they’ve reached out to and have actively taken an interest in participating in these activities.” On an individual level that transcends to the organizational level over time, a tactical level participant developed relationships with other health providers from the U.S. military. They said, “I spent most of my time, maybe by choice, with American healthcare providers, that’s what we did and even in our off-times that’s what we did. We sort of bonded and that’s where we worked and that’s where we sort of stayed.”

HN: According to host nation participants, relationships are challenging in Timor-Leste, but the hospital ship was successful in developing them between the participants and the Ministry of Health. A senior level participant said, “I’ve been working here on and off for about ten years now with Timor-Leste and I know that partnership is quite difficult. Many often when you meet, everything is organized but when it comes to actually doing the work and implementation, everybody seems to be busy with other things. And I think during the mission, it was actually very successful in the sense that everybody was involved and excited as well, and even the population were excited because the media got involved. They announced it on TV. So it was a big event.” The participant went on to say how the hospital ship mission assists in developing relationships between U.S. Government partners working in Timor-Leste and the Ministry of Health. They stated, “in terms of relations with the U.S. Embassy and also with the USAID team, it’s an opportunity because the Ministry has always new team coming into the system and it’s an opportunity for them to get to know who’s who and that relationship continues afterwards. I remember meeting the General, I can’t recall the name, and I saw him afterwards and communications afterwards is much easier when there is any need from the Ministry to the U.S., we know who to contact sometimes when we don’t get to the right person or the right unit and from that side, also, the same, with USAID and so they know who’s who now.”

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NGO: Long-Term Relationship

The hospital ship mission did facilitate the development of relationships between NGOs as well as “prior enemies;” however, the impact of these relationships beyond the mission was left in question. One participant with experience on two hospital ship missions said, “we’ve got a great working relationship with all the NGOs that partner. It hasn’t expanded into anything beyond that so that may be indicative of something… NGOs, in general, are kind of in a competitive environment and so I think outside of these missions, there’s no additional activity.” Another operational level participant was more optimistic and lauded the impact the missions have on forging relationships with prior enemies by stating, “when you work together with something, you gain confidence in one another, somehow you work, even former enemies can come together.”

NGO: Short-Term Relationship

The hospital ship mission assisted in developing relationships between the short-term relationship NGOs, the Navy, and host nation personnel. An operational level participant said, “it’s not so much the curing of the sick and taking care of them, that’s all very nice but I think it’s just an absolutely wonderful way to do public relations, establish relations with the rest of the world.” A tactical level participant said, “it has given us a relationship with the Navy that we didn’t have previously…I kept in touch with many of my colleagues on the ship.” Another participant stated, “we went to the Ambassador’s house…you know, dinner and get-together with some of the heads of the country there and that was good. I think it just definitely had a very positive impact on the country’s leadership relationships.”

NGO: Local-NGO

The hospital ship mission was credited with developing the relationship of the local NGOs with other participants such as USAID, the Ministry of Health, and broader NGO community. Most of the relationships were ongoing and the mission further enhanced what existed. An operational level participant stated, “I think positive components were getting, I said the Ministry weren’t at any of the meetings that I was at, but getting NGO community and hospital kind of partners discussing the ship and how we could try and help maximize the effectiveness of this many health personnel and facilities. That a positive because it brought us together.” A tactical level participant went on to say, “during the mission we had often communication with USAID and after the mission, because we have a communication system for the project, we have a assigned person in the USAID, we really keep in touch, but during the mission it was more intensive for the sake of the mission. And definitely, if we talked to them more and more then it helped us a lot to build up relationship with USAID.”

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Evidence from Documentary Review

Policy:

DoD Instruction 3000.05 Stability Operations (2009): This document was published by the Under Secretary of Defense for Policy and reissued the DoD Directive Military Support for Stabilization, Security, Transition, and Reconstruction (SSTR) Operations as a DoD Instruction. The Under Secretary of Defense for Personnel and Readiness is assigned the responsibility to “develop policy and opportunities for personnel from other U.S. Government agencies, foreign governments, international organizations, and nongovernmental organizations to participate, as appropriate, in DoD training related to stability operations.”

DoD Instruction 2205.02 Humanitarian and Civic Assistance (HCA) Activities (2008): This document was published by the Under Secretary of Defense for Policy and outlines policy for the conduct of HCA activities. The Instruction states these activities may “involve cooperation with host-nation military or paramilitary elements (to include the participation of third party organizations such as NGOs or private and/or voluntary groups) to establish trust and enhance relations with those entities.”

National Security Presidential Directive-44 (NSPD-44) on Management of Interagency Efforts Concerning Reconstruction and Stabilization (2005): This directive was published by The White House “to promote the security of the United States through improved coordination, planning, and implementation for reconstruction and stabilization assistance for foreign states and regions at risk of, in, or in transition from conflict or civil strife.” This document states the U.S. “should work with other countries and organizations to anticipate state failure, avoid it whenever possible, and respond quickly and effectively when necessary and appropriate to promote peace, security, development, democratic practices, market economies, and the rule of law.”

Guidance:

Sustaining U.S. Global Leadership: Priorities for 21st Century Defense (2012): This document was published by the Department of Defense and provides strategic guidance for the DoD to meet new priorities for a 21 st century defense to sustain U.S. global leadership. These priorities include shaping a smaller and leaner Joint Force, maintaining a global presence emphasizing the Asia-Pacific and Middle East, and “ strengthening alliances and partnerships across all regions .” The guidance states “ our relationship with Asian allies and key partners are critical to the future stability and growth of the region. We will emphasize our existing alliances…expand our networks of cooperation with emerging partners … The U.S. is also investing in a long-term strategic partnership with India to support its ability to serve as a regional economic anchor and provider of security in the broader Indian Ocean region…Working closely with our network of allies and partners , we will continue to promote a rules-based international order that ensures underlying stability and encourages the peaceful rise of new powers, economic dynamism, and constructive defense cooperation.”

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National Military Strategy of the United States of America: Redefining America's Military Leadership (2011): This document was published by the Chairman of the Joint Chiefs of Staff to provide ways and means for the military to advance the national interests defined in the 2010 U.S. National Security Strategy. Three broad themes are described: 1) “a Joint Force leadership approach, 2) a need to deepen security relationships with our allies and create opportunities for partnerships with new and diverse groups of actors, 3) the need to prepare for an increasingly dynamic and uncertain future.” The document acknowledges, “in this interdependent world, the enduring interests of the U.S. are increasingly tied to those of other state and non-state actors.” It goes on to state “we must play a supporting role in facilitating U.S. government agencies and other organizations’ efforts to advance our Nation’s interests.” Directly in line with hospital ship missions, the document specifies “as a convener, our relationships, values, and military capabilities provide us, often uniquely, with the ability to bring others together to help deepen security ties between them and cooperatively address common security challenges…we will be prepared to act as security guarantor – preferably with partners and allies , but alone if necessary – to deter and defeat acts of aggression. For all of these leadership approaches, we will pursue wider and more constructive partnerships …Humanitarian assistance and disaster relief activities employ the Joint Force to address partner needs and sometimes provide opportunities to build confidence and trust between erstwhile adversaries. They also help us gain and maintain access and relationships that support our broader national interests.”

DoD Quadrennial Defense Review (2010): This document was published by the Secretary of Defense and provides direction to reforming the DoDs current capabilities and requirements in order to meet future challenges. The document recognizes “ the importance of revitalizing defense relationships with allies and partners in key regions. An important element of revitalizing key relationships is the need to craft an approach to the U.S. defense posture that emphasizes cooperation with allies and partners …”

U.S. National Security Strategy (2010): This document was published by the White House and sets forth guidance for all U.S. Government agencies to meet the specified national security priorities and objectives. Within the National Strategy, expanding existing global alliances and partnerships features prominently as a driver of a more secure environment. Specifically, the strategy states “ We are working to build deeper

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and more effective partnerships with other key centers of influence…so that we can cooperate on issues of bilateral and global concern, with the recognition that power, in an interconnected world, is no longer a zero sum game .” Identified as a top national security priority, the U.S. “ broader engagement with Muslim communities around the world will spur progress on critical political and security matters, while advancing partnerships on a broad range of issues based upon mutual interests and mutual respect .” This includes “ developing new partnerships in Muslim communities around the world on behalf of health, education, science, employment, and innovation .” As it relates indirectly to Pacific Partnerships, the strategy states “Our alliances with Japan, South Korea, Australia, the Philippines, and Thailand are the bedrock of security in Asia and a foundation of prosperity in the Asia-Pacific region. We will continue to deepen and update these alliances to reflect the dynamism of the region and strategic trends of the 21 st century.”

Joint Publication 3-29: Foreign Humanitarian Assistance (2009): This document was published by the Director of the Joint Staff and “provides joint doctrine for planning, executing, and assessing foreign humanitarian assistance operations.” Key Non-U.S. Government participants and organizations involved in foreign humanitarian assistance are identified and include the host nation, UN, NGOs, private sector, and private contractors. It is interesting to note these organizations are categorized as “participants” and not “partners.” This observation is reinforced when the document states “ The joint force will work not only with interagency partners during FHA operations, but also with multinational organizations including the HN, IGOs, NGOs, partner nations, and the private sector .” Another program discussed in detail that builds partnerships between the DoD and foreign countries is the U.S. National Guard State Partnership Program (SPP). The mission of this program according to the publication is to “ build genuine state partnerships which mobilize the entire social fabric of American support to democracy abroad…Partnerships will create long-term personal relationships based on openness, confidence, and trust .” According to the publication, this program “ has proven to hasten and expedite USG response to humanitarian crisis through this reach-back capability…The SPP’s build enduring military-to-military, military-to-civilian, and civil security cooperation relationships that enhance long-term international security while building partnership capacity across all levels of society .”

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“1) Strengthen existing Alliances and leverage them to shape the environment for building multilateral relationships and a more effective presence; 2) Enhance Alliances and partnerships to build capacity over the full spectrum of military activities; and 3) Promote military professionalism and enhance interoperability among Allies and partners to build trust and increase multilateral effectiveness.”

DoS Quadrennial Diplomacy and Development Review, Leading Through Civilian Power (2010): This inaugural document was published by the Secretary of State in order to provide strategic direction to both the DoS and USAID in order to meet the National Security Strategy objectives. When describing America’s role as a global leader, the QDDR asserts “ Leadership today requires us to work and partner with others in pursuit of shared objectives, starting with our traditional allies with whom we hold a longstanding community of interests and values, and including emerging centers of regional or global influence, and non-state actors from NGOs and corporate partners to religious groups and individuals .” This will be achieved by building “ a network of alliances and partnerships, regional organizations and global institutions, that is durable and dynamic enough to help us meet today’s challenges, adapt to threats that lie ahead, and seize new opportunities .” Through this and other efforts to elevate regional engagement, “ State and USAID will become stronger partners with the Defense Department’s regional Combatant Commands. Drawing on the successful experience of partnering with the U.S. Southern Command, we will make available to the Department of Defense senior Ambassador-ranked personnel as civilian deputies to Combatant Commanders in addition to existing Foreign Policy Advisors, where such appointments effectively advance our national interests…USAID will continue to appoint high-level development advisors to COCOMS where appropriate…and welcome the opportunity to detail mid to senior-level State and USAID personnel to COCOMs to improve working- level cooperation with the Department of Defense .” The QDDR states, “ Our diplomats need the training and the means to building these innovative new partnerships ” and highlights areas where the DoS will adapt U.S. diplomacy to meet new challenges. These areas include “ deepening engagement with our closest allies and partners…building relations with emerging powers through Strategic Dialogues that connect experts throughout our government with their counterparts in partner countries .” The QDDR describes the need to connect with “ NGOs, corporations, civil society groups, and individuals around the world who share our goals and interests…and designing programs, projects and partnerships with them to advance America’s security, prosperity and values around the world .” Furthermore, “ We must build partnerships and collaborate – within our government, with local partners, and with international organizations – to engage in the difficult work of helping to bring conflicts to an end. We will build this U.S. civilian capacity in close coordination with our military partners.”

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community and our social and economic relationships with East Asia in this ‘Asian century.’”

Planning/execution:

Pacific Partnership 2010 Timor-Leste Nularan Primary School ENCAP – NMCB Eleven After Action Report Jul-Sep 2010: This report describes the deployment of the Naval Mobile Construction Battalion ELVEN to Timor-Leste in support of renovating the Nularan Primary School in Dili, Timor-Leste. The team was deployed in advance of Pacific Partnership 2010 to initiate the renovation of five buildings at the school and prepare the location for completion during the arrival of the Mercy hospital ship during PP10. This included cosmetic and structural repair to 22 classrooms and replacing roofs, a septic system, windows, doors, etc. The Navy Seabees managed “a team of 101 military engineers including 84 direct labor plus an additional 22 civilian volunteers and contractors who expended in excess of 2500 man days of labor…military engineers from three countries were able to work together, learn from each other, and build bonds of friendship and partnership .” Project participants included the U.S. Navy Seabees, Timor-Leste F-FDTL, Timor-Leste International Stablisation Force (Australian military), as well as Navy Seabees and Australian Defence Force personnel assigned to the Mercy during PP10. In the context of partnership impact, the report states, “ This project will be a lasting visible symbol of United States goodwill and partnership with Timor-Leste .” The report also quotes a DoS blog established by the dedicated Foreign Service Liaison Officer for PP10 that stated “Perhaps the showcase PP10 project jointly accomplished by

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U.S. Navy Seabees and Australian engineers is the sprawling compound of the Nu Laran school…”

USNS Mercy (T-AH 10) and Pacific Partnership May-September 2008 Post Deployment Brief (Unclassified): This briefing was presented by the USNS Mercy Medical Treatment Facility Commander and clearly stated in the notes section of the first slide that the mission was an “ Incredible opportunity for America and our partners to make a global difference .” The brief provides historical context and describes the current priorities and efforts as “ Strengthening relationships with host and partner nations. Building partner capacity to conduct peace, stability, and consequence management operations. Improving U.S. & Partner Humanitarian Assistance & DR capacity. Improving security cooperation among partner nations .” A single slide in the briefing is dedication to the partners and is entitled “We value our Partners” and prominently features photographs of the various participating organizations. Within the notes section it states “ What makes Pacific Partnership work are the relationships between all participants working together with the Host Nations to promote the government, health and engineering infrastructure and the HN citizens .” Additionally, “A great success this year was the diversity of our team, the cultural experience and the large numbers of participants from many different organizations and countries who are now trained to work together during a future HCA mission or disaster, either at home or abroad.”

Distribution of Themes among Participants

Within Units of Analysis

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Across Units of Analysis

Means for Testing

Triangulation

Data emerged from different sources to include the key stakeholder interviews and documentary review.

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

Theme emerged between units of analysis: Strategic, operational, and tactical levels.

Reliability/Internal Validity

Theme was mentioned in 37 sources and referenced 164 times.

Theme is considered a plausible element of the theoretical framework.

External Validity

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

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Appendix R. Theme: Developing New Perspectives

Key Findings Summarized

This theme was the second most prominent of the 15 themes emerging from the key stakeholder interviews. Developing new perspectives is a plausible element of learning as depicted in the theoretical framework (Figure 7) and featured in 33 key stakeholder interviews, within all units of analysis, and across all levels of participation. Among the 155 references coded, operational participants (42.1%) most often cited this theme followed by tactical (33.9%) and strategic level (24%) participants. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of developing new perspectives. The theme was triangulated during the documentary review where developing new perspectives featured in 1 (20%) policy, 7 (58.3%) guidance, and 2 (40%) planning/execution documents reviewed.

Evidence from Interviews

Within Units of Analysis

USG: Military

The theme of developing new perspectives featured prominently during the key stakeholder interviews. New perspectives in conducting HA and about other partners were gained by military participants. A member of a pre-deployment site survey team stated, “And so I think the experience that everyone, all DOD who is there had, it’s learning a new skill. It’s a skill that I did not have. Prior to this I drove warships and operated nuclear reactors, and so this is a completely new skill that I developed and that’s helpful.” They went on to say, “and then the NGOs in Timor for planning and stuff like that, the Australia-Asian Physician Group that helped staff all the hospitals in Timor, they were very helpful to meet with and work with and we learned a lot about the needs of Timor.” A senior level medical participant reflected, “Our guys get to see and practice medicine and doctoring that they wouldn’t be able to do in a lot of other countries. I mean, there’s literally, you go to some of these places, these people have never seen a doctor.” Other military participants felt other U.S. partners gained a new perspective of the military as a result of the hospital ship mission. A senior level participant mentioned, “to develop those relationships and common understandings is good with partner nations, but the other thing is DOD learning how to work with NGOs, learning how to work with State, that’s important different cultures. You’ve probably seen this. We talk differently. We have a bazillion people. They have one. There’s a lot of cultural barriers to communication. So that happens sometimes… I think State and USAID benefit likewise from getting a better understanding or appreciation of what we can bring to the table.” A medical participant stated, “I think the hospital ship is a laboratory and it’s an exhibit. It’s a display of what a perfect hospital can look like…we use the hospital ship best when

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we’re bringing host nation providers, medical personnel aboard the ship and we show them infection control practices. We show them inpatient management, how we move people through the system, recordkeeping… I think it’s very good to have all these partner nations see the hospital ship, to live on the hospital ship so they know the capabilities because who knows where the next disaster or anything like that will be.” Another mentioned, “Indonesia, you know, they send ten physicians aboard and ten other type of medical personnel and they kind of just work with us. They see a lot of patients. They teach. They give us some insight into local languages and things like that. On their end, they learn about the hospital ship, the operation. They learn better about how the Navy works and stuff like that, so that if we ever have to work with them in the future, they integrate much better.” The feeling of HN personnel gaining a new perspective of the U.S. was described by another as, “by bringing the parliamentary leadership onboard they were able to witness firsthand the capabilities that our military has in the area of medical services.” A senior level official extended this learning of a new perspective beyond senior level personnel to include the host nation population writ large. They mentioned, “if you just save some little kid’s father’s life, he knows an American doctor or a doctor from Singapore on the American hospital ship, you know, did X, Y, and Z, that little kid will remember that. So maybe we’re cutting down on the number of terrorists that are going to grow up to hate us or just people that grow up to hate us in general.”

USG: Non-Military

A senior level participant felt the U.S. Navy gained a new perspective as a result of the hospital ship mission. They said, “the U.S. Navy, I think, knows that they can visit Timor. They know what types of activities they can do there. They have certain, I think, realistic expectations about local capacity and local partnership and local buy-in to these activities and I think, in that sense, that’s really important.”

PN: Pacific Region Presence

This theme featured prominently and focused on the partner nation military learning how to conduct HA as well as partner with NGOs. The partner nations also highlighted the U.S. as a learning organization willing to develop new perspective by listening to partner recommendations. A tactical level participant stated, “Oh, I think it’s been a fabulous benefit, just in the fact that we don’t have a lot of humanitarian work and I think it’s just made some people in the Defence Force think about what we can do in our backyard, so to speak.” A senior level participant said, “the U.S. Navy planners, as I alluded to earlier they listened to what A, we, as a partner nation, had to say and they listened to the NGO organizations and what they had to say, and we were viewed as force enablers, I guess, but we really had no impact on the overall mission.” Another tactical level participant stated, “it was hard work but it opened my eyes up to a whole different way of working together because I was always used to never actually working in partnership with somebody. It was only going into work for somebody or going somewhere and these people work for you. It was always that military style to it, never so much of actually

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working with people and especially on an equal footing like that.” They also describe the unique opportunity to partner with the NGOs by saying, “I’ve never worked with NGOs before. I didn’t know how this was going to go but I thought everything worked really, really well… Yeah, (partner nation name deleted) doesn’t use NGOs to anywhere near the way that the U.S. does at all. It just doesn’t happen. I mean, the only civilian people that we see are contractors. There’s really, I don’t deal with NGOs in the Navy at all. They’re just not there.”

PN: Non-Regional Presence – N/A

The partner nation military developed new perspectives regarding the delivery of HA and joint operations as a result of the hospital ship mission. A senior level participant said, “our medical people are doing stuff that they wouldn’t be doing otherwise, going into a country such as Vietnam or Timor-Leste and actually putting boots on the ground and treating, providing humanitarian assistance and treating people that really need it. So, from a pure learning perspective, capability building, that is great for us…We are deploying on an exercise which uses land, air, and sea assets all at once. It is truly a joint type operation and it’s great for us. It just gives us, like I said, an opportunity to exercise something that we would not normally have an opportunity to do.” A tactical level participant echoed this sentiment when they said, “we have a very small military and we do not have an opportunity such as Pacific Partnership to exercise our medical folks using a variety of different platforms such as a Navy ship, landing crafts, helicopters.” New perspectives in health care delivery were also gained as described by one tactical level participant, “we all bring different skills and then we learn from other people. So our care was constantly getting better.”

HN: Host-nation participants described new perspectives in terms of health services provided and equipment necessary to support these services. One participant stated, “We get some points from them. We learn something new. As you know that East Timor at the moment is very limited in the human resource and so that situation is very helpful, although we know that this is temporary.” Host nation participants also described the technology available through the hospital ship mission. A senior level participant said the hospital ship “really show how the high tech technology, we always see the big ships with the high tech can really provide a good assistance to the people, especially in Timor- Leste with very limited tertiary care facilities… the technology that’s inside the ship was very precious for country like Timor.”

NGO: Long-Term Relationship

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down your medicine,” but, you have to put it at a more basic level. So, the partners that you work with over there, the host nation people, they help you to understand that and you have to be careful not to say, “Oh, my God, how can you do that?”

NGO: Short-Term Relationship

New perspectives were developed among short-term NGO participants through joint training with other partners, to include the host nation, during the hospital ship mission. One tactical level participant recalled, “on the way over we did lots of in-services where we did a lot of teaching and sharing of skills. It was just a good way to get to know each other as different groups, how to operate within the parameters of our scopes of practice because each one of us had did different things.” Another stated, “I think there was obviously lots of education involved in terms of us learning from the countries and then the countries learning skills and a new way of looking at things from us.”

NGO: Local-NGO

Local NGOs developed new perspectives from the military in how to operationalize health services in a rapid fashion and on a large scale. An operational level participant stated, “something that I am full of admiration for, I have to say, and got us thinking about how we could deliver services differently, actually, is the way the military pulls off organizing a clinic in a field and given that, a national initiative called SISCa here is the monthly outreach, trying to deliver services in remote communities. It’s incredibly resource intensive and it’s way off perfect but we’re all working to support it, and then the military team turned up and I got to see these tents and it wasn’t just tents, it was the way the teams organized the community in terms of the queuing, ensuring that the flow of patients was fast, that people weren’t queue jumping, crazy stuff. I know that sounds silly but it was incredibly impressive to watch how, the logistics of setting up an outreach clinic and I did say that to them there. It was quite a thing to behold and I say there are lessons in there for us, given that’s exactly what goes on virtually every day of the month here but it’s chaos.” They also said, “I think there was some really interesting things and I’ve been trying to think how I can operationalize some of those. So that was a, for me, that was a real success.”

Evidence from Documentary Review

Policy:

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information sharing with relevant U.S. Government departments and agencies, foreign governments and security forces, IOs, NGOs, and members of the private sector...Develop and provide opportunities for personnel from other U.S. Government departments and agencies, foreign governments, IOs, and NGOs to participate in DoD training related to MSOs and in non-DoD education and training programs relevant to health, including stability operations, security cooperation, humanitarian assistance, disaster response, irregular warfare, health diplomacy, and health sector capacity building…Develop measures of effectiveness that evaluate progress in achieving the MSO goals.”

Guidance:

DoD Quadrennial Defense Review (2010): This document was published by the Secretary of Defense and provides direction to reforming the DoDs current capabilities and requirements in order to meet future challenges. The QDR acknowledges the need to reform existing security assistance programs in order to more effectively build partner capacity and increase the “ability to sustain long-term efforts.”

U.S. National Security Strategy (2010): This document was published by the White House and sets forth guidance for all U.S. Government agencies to meet the specified

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national security priorities and objectives. Understanding the role of the private sectors, the strategy asserts “ we must tap the ingenuity outside of government through strategic partnerships with the private sector, nongovernmental organizations, foundations, and community-based organizations. Such partnerships are critical to U.S. success at home and abroad, and we will support them through enhanced opportunities for engagement, coordination, transparency, and information sharing. ”

Joint Publication 3-29: Foreign Humanitarian Assistance (2009): This document was published by the Director of the Joint Staff and “provides joint doctrine for planning, executing, and assessing foreign humanitarian assistance operations.” This version updates the 2001 publication by identifying and recognizing the essential roles of non-US Government participants and organizations, identifies USAID as the lead agency for US bilateral development and humanitarian assistance, further details the civil-military operations center composition and function among other areas that either directly or indirectly impact partnerships and hospital ship humanitarian assistance missions.

Planning/Execution:

USNS Mercy (T-AH 10) and Pacific Partnership May-September 2008 Post Deployment Brief (Unclassified): This briefing was presented by the USNS Mercy Medical Treatment Facility Commander and clearly stated in the notes section of the first slide that the mission was an “ Incredible opportunity for America and our partners to make a global difference .” In a medical context, the presentation states “It’s the participation, not the numbers of patients that is important.” A critical element incorporated into the hospital ship mission deployment is the predeployment site survey (PDSS) team. The team composition is provided in the briefing and it is composed of military personnel, no other organizations participating in the mission were included. However, the briefing does recommend adding USPHS personnel to future PDSS teams. The briefing described many partnership themes in a slide titled “Opportunities for Cooperation” and include the following: ““Understand civilian agency culture, priorities and decision making process; Provide access for our Partners to develop their own HN relationships; Be complementary to the partners that form the team, by being aware of their efforts in the Region ; Trust among all is crucial; Social networking and relationships enable the willingness to share; Leadership that motivates organizational change to promote sharing.”

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Pacific Partnership 2008 Post Deployment Brief, Briefing to Commander, U.S. THIRD Fleet (Unclassified): This briefing was provided to the Commander, U.S. THIRD Fleet by the Pacific Partnership 2008 Mission Commander after the conclusion of the mission. Mission highlights related to partnerships included “ effective integration of reservists, partner nations, and NGOs ” while lowlights included “ coordination to identify number and skills of Reserve, Partner Nation and NGO personnel and inconsistent support of mission by country teams. ” The mission endstate was described as “ host nations, partner nations, and NGOs seek further participation in Pacific Partnership .” Furthermore, “US access, influence, and reputation are enhanced” which was achieved in by, “hospital ship increases favorable perception – powerful symbol of commitment and compassion.” In the first slide, one defining aspect of the mission was described as “longer duration port visits increased engagement quality” which included “greater community interaction.” Background, challenges, and significant achievements and next steps were outlined for each country visited during the mission. For Timor-Leste, the mission was described as “reinforcing ISF objectives” while listing “limited capacity of HN Ministry of Health” as a challenge – both partners in the hospital ship mission. Next steps in Timor were described as “ Continue to leverage Portugal and Indonesia as partner nations in Timor- Leste ” and “ seek opportunities to help develop a professional military. ” The briefing concludes with recommendations suggesting what the Chief Naval Officer (CNO) can do to support and included the following related to partnerships: “Designate single coordinator for NGO participation and integration; Expand Navy’s pool of NGO participants, Seek synergistic, additive capabilities vice manpower relief; Advocate joint and interagency coordination of HCA efforts.”

Distribution of Themes among Participants

Within Units of Analysis

239

Across Units of Analysis

Means for Testing

Triangulation

Data emerged from different sources to include the key stakeholder interviews and documentary review.

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

Theme emerged between units of analysis: Strategic, operational, and tactical levels.

Reliability/Internal Validity

Theme was mentioned in 33 sources and referenced 155 times.

Theme is considered a plausible element of the theoretical framework.

External Validity

Theme emerged with in multiple units of analysis: USG, PN, HN, and NGO.

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Appendix S. Theme: Developing Credibility

Key Findings Summarized

This theme is a plausible element of building connections as depicted in the theoretical framework (Figure 7) and featured in 26 key stakeholder interviews, within all units of analysis, and across all levels of participation. Among the 59 references coded, operational participants (55.1%) most often cited this theme followed by tactical (26.2%) and strategic level (18.7%) participants. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of developing credibility. The theme was triangulated during the documentary review where developing credibility featured in one (20%) planning/execution document.

Evidence from Interviews

Within Units of Analysis

USG: Military

The hospital ship missions facilitated the development of credibility between organizations and with the HN population. The latter included building the credibility of the HN military with the HN population. This was described by one participant when they said, ““we did have a team of F-FDTL medics being taught by Australians, and they’ve gone through basic medic training and they were really excited about getting them involved in our MEDCAP sites. And so we had a group of I think it was probably up to ten, maybe five to ten at each of our MEDCAPs…we had them doing the initial screening, you know, a civilian would come in and say, “My leg hurts,” and they’d say, “Okay, well, you know, put on this color band on your arm and go stand in that line.” And so they were really, it wasn’t a holding their hand, it was a partnership where they were bringing their skills to the table and we were bringing our skills. Their skills were, I mean, excellent translators and they had excellent awareness of what these people needed and how to communicate with them and what questions to ask them.”” One participant described credibility between participants and the HN population as, “A huge part of the mission is just when we put hundreds of American and partner nation people through the country. It just builds a lot of goodwill and support among the population when they see us, you know, MEDCAPs, showing compassion, empathy, and things like that. I think that’s a huge kind of long-term goodwill builder, which helps support infrastructure. It helps support all our programs. Going to MEDCAPs, seeing a local population, I think it just helps with all that, even though that’s not capacity-building necessarily, the MEDCAPs and stuff like that, but it’s still helpful. So the actual delivering of care, direct care, I think, supports our mission.” Credibility between participants was also developed. One senior level military participant highlighted this when they said, ““If I have to work with the Church of Latter Day Saints again, I understand the huge number of resources they have and how easy it is to tap into them and how professional their people are. I would never be afraid to work with them in something, again, whereas your

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initial thinking is, “Ew, Church of Latter Day Saints, Mormons are going to be proselytizing, getting, you know,” not, you know, never happened.””

USG: Non-Military

There was a sense among non-military participants the U.S. developed credibility with the host nation. A senior official stated, “we were able to engage many members of the Timorese Parliament during the Mercy’s visit from the straightforward provision of medical services to those members of Parliament but also by bringing the parliamentary leadership onboard they were able to witness first-hand the capabilities that our military has in the area of medical services.” A participant with the experience of multiple hospital ship missions said, ““from the defense point it was a success even for Timorese people because, well, Timorese people think that, “Okay, the United States military consider us a good friend and then you collaborate with them, particularly when they support F-FDTL. They know that F-FDTL is very sweet, yeah and the U.S. military is providing a lot of supportive leadership and people are perceive that…It’s very rare for a very sophisticated military to come and work with, you know, military that in the stage of development and also I can see that the defense, our military, they like working with United States more than, this is all my opinion, I might be wrong, than with Portuguese military.””

PN: Pacific Region Presence

During the hospital ship missions, the U.S. gained credibility among the partner nation militaries for their ability to conduct the mission and in turn, provided credibility to the partner nation for participating. Additionally, NGOs gained credibility for their work performance and their willingness to contribute in a volunteer capacity. A senior level participant claimed, “to go out there and do MEDCAPs and deliver health effects in four or five different areas on a reasonably small island, you know, every single day of the week for three weeks, as well as taking, admitting people onto the ship was massive. And without a doubt and I’m not blowing smoke, America’s probably the only country who could still do that… so it’s credibility for us that we can force project and we can go out and do it but we know over here that our lead partner will always be America.” A tactical level participant with multiple missions of experience said, ““A lot of people might not have understood about exactly what NGOs do and the fact that those people were volunteering their time. I think because you all get to talking around the dinner table and when you hear that these people are just volunteering their time, you think, “Wow, that’s a very big thing of you to do,” and you could see the look in other people’s faces that they were like, “Wow, well, we’re being paid for this but you’re not.”’ Another tactical level participant recalled, “I think it was called Smile Power or something, they did a lot of cleft palates for patients and they were an outside organization that were on the ship and we thought the work that they did was amazing."

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PN: Non-Regional Presence

Job continuity facilitated relationships that over time matured and yield credibility to the partner nation military. A senior level participant said, “I did feel that because the continuity was there…I maintained excellent relationships with your COCOM or my COCOM counterparts for the planning and in this particular case, the N5 shop and that continuity, I think, assisted me in getting in the door.”

HN – N/A

NGO: Long-Term Relationship

Credibility was gained between NGO participants as a result of the mission. An operational level participant said, ““I was a little concerned about the Latter Day Saints because they had a big contingent, probably sixty people and that’s a religious organization. I’m thinking, “Oh, man, how is that going to work?” And, they turned out to work real well, I mean, nothing against religious organizations but we’re certainly not over there to try and convert people and stuff and that worked out real well.”” A prior military member now serving in the NGO at an operational level said, “as far as my former military status…it was a help because the other NGOs kind of looked to us. I think they understood we knew the ropes a little better.”

NGO: Short-Term Relationship

The U.S. military gained a deep level of respect among the short-term NGOs as a result of the hospital ship mission. An operational level participant said, “I think that it’s a fascinating thing to be able to put a hospital together basically in a day with, with all the players coming to the floor at one time. I think that’s a fascinating accomplishment that the scope of the project is so huge, not just for us individually but for the Navy it is rather fascinating that that happens. I think that’s an amazing accomplishment.” Furthermore, “I personally have a strong respect for the Navy and so I think that is from a personal aspect, I have appreciated the opportunity to get to know a lot of really great people in the military on an individual basis.” A tactical level participant said, “I got on very well with all of the Navy and Army personnel and I hope that people found us helpful and professional and an asset to the team. So I, you know, I don’t have a bad word to say against anybody of the Navy, so I do hope it worked the same way but I don’t know.”

NGO: Local-NGO

The hospital mission conveyed a sense of benevolence and increased the credibility of the U.S. among the host nation population according to the local NGOs. A participant with many years of experience working in Timor-Leste said, “honestly speaking here it’s like the Timorese, they sometimes, they don’t like the Australians AID because they believe that they’re getting petroleum product like the oil from here. So although the AUSAID is one of the biggest donor, largest donor for the government the general people and even the government people, if any support come by AUSAID they usually consider, look for

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the hidden objective. But here, it’s the benefit for the American government like they don’t have any, they consider that America doesn’t have any hidden objective and it’s a gift from the American government for Timor-Leste.”

Evidence from Documentary Review

Planning/Execution:

Distribution of Themes among Participants

Within Units of Analysis

244

Across Units of Analysis

Means for Testing

Triangulation

Data emerged from different sources to include the key stakeholder interviews and documentary review.

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

Theme emerged between units of analysis: Strategic, operational, and tactical levels.

Reliability/Internal Validity

Theme was mentioned in 26 sources and referenced 59 times.

Theme is considered a plausible element of the theoretical framework.

External Validity

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

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Appendix T. Theme: Sharing Resources

Key Findings Summarized

This theme is a plausible element of generating action as depicted in the theoretical framework (Figure 7) and featured in 32 key stakeholder interviews, within all units of analysis, and across all levels of participation. Among the 88 references coded, operational participants (50%) most often cited this theme followed evenly by strategic (26.0%) and tactical (24.3%) level participants. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of sharing resources. The theme was triangulated during the documentary review where sharing resources featured in 1 (20%) of policy and 10 (83.3%) of guidance documents reviewed.

Evidence from Interviews

Within Units of Analysis

USG: Military

This theme emerged between U.S. military participants and other participants already working in Timor-Leste as well as with NGOs on the hospital ship. One participant stated, “Working with the Australian military was key. In 2008 they provided our security on the ground for VKK when we were there.” Another mentioned, “We have Seabees in country on site. The Seabees we had with us and the engineers with us partnered with them to do some restoration of schools and clinics.” Regarding local NGOs, one participant recalled, “the NGOs took care of transporting patients to, bringing them to us and then also helping out at the sites, and again it wasn’t, we weren’t teaching them and showing them how to do things. It was that they were doing their role, we were doing our role, and we were doing them together.” One participant mentioned, “being able to host Operation Smile, we gave them their own operating room so they could do all their, they brought all their own people, all their own supplies.”

USG: Non-Military

The sharing of resources between participants, primarily the U.S. and Australia, was identified as success to the partnership. One senior official said, “I’m pretty sure that the Australians sent two landing vessels––and so that actually gave us the capacity to sort of reach areas and deliver services to areas that we might not otherwise be able to do and it was significant.” Another participant mentioned, “A far more important supporting partner was the Australian military, the Australian Defense Force. Their support, logistic, administrative, material, you name it, was essential, transportation, my goodness, was essential to the success of the Mercy.”

PN: Pacific Region Presence – N/A

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PN: Non-Regional Presence

The hospital ship mission facilitated the sharing of resources between the military partners to increase efficiency and capability. One participant described what would occur after a planning conference where they would “come back to (partner nation name deleted) and look at our capabilities and to see what kind of additional resources we could put on the ship to assist in carrying out the mission.” Another participant highlighted, “Australia, New Zealand, Japan and other nations coming to the forefront and they’re bringing ships with them now and they’re bringing more capability.”

HN: Through the sharing of hospital ship mission resources, host nation participants were able to support one of their ongoing programs. A senior level participant said the SISCa program was designed, “to make sure that our health staff can visit every village, every house to give assistance once a month but it’s very difficult, this constrain, lots of constraining in part of their role during the rainy season logistically. And then the arrival of the Mercy ships with the huge personnel with the high tech technology, you can easily travel by fly with the helicopter to every village.”

NGO: Long-Term Relationship

There was recognition among the long-term NGO partners that the hospital ship missions resulted in a sharing of resources although the contribution of each was left to question. A senior level participant with the experience of multiple hospital ship missions said, “the cost of deploying a civilian volunteer is 100% less than deploying an uniformed provider, plus a half-dozen other different measures of MHS effectiveness. So that being the case, why can’t the DOD contribute towards the logistical deployment of civilian providers?”

NGO: Short-Term Relationship

The short-term NGO acknowledged the resources they contributed to the hospital ship mission. An operational level participant said, “(NGO name deleted) put in, I guess, several million dollars of humanitarian supplies to be distributed over there and of course that’s why we were working with the Chaplains to distribute those onshore.”

NGO: Local-NGO

Local NGOs contributed to the hospital ship mission by providing resources and also gained a better understanding of what other partners contributed to the success of the mission. One tactical level participant said, “we provide the accommodations and support to bring those people to the U.S. Mercy ship and we also allocate about four of our staff to companion with them while they were staying in the boat to get medical assistance…and it was very successful because all of the children get operated and then so it was very successful for our side.” Another operational level participant said, “So we have obviously produced many health films and we have lots of health promotion education and so I spoke to the military personnel about what about if we can capture the

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fact that those people stood there for ages and we could be delivering health promotion messages.” A third participant observed, “in 2010 it was very clear that each of the partnership, they play different roles. Some provide logistical. Some provide other services, transportation, communication, some coordination.”

Evidence from Documentary Review

Policy:

DoD Directive 5100.46 Foreign Disaster Relief (FDR) (2012): This document was published by the Under Secretary of Defense for Policy and sets forth policy and responsibilities for FDR operations. Responsibilities include “DoD shall respond to foreign disasters in support of the U.S. Agency for International Development…” It goes on further to state military Components (e.g. Army) “shall provide disaster assistance only when the Secretary of Defense…approves, with the concurrence of the Secretary of State…” Additionally, “DoD shall consider FDR assistance requests from USAID, the Department of State, and other Federal departments and agencies based on USG and/or appropriate international organization assessment(s) of the disaster…”

Guidance:

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assistance, the document claims “Although the U.S. military can and should have the expertise and capacity to conduct these activities, civilian leadership of humanitarian assistance, development, and governance is essential. The Department will retain capabilities designed to support civilian authorities as needed.”

U.S. National Security Strategy (2010): This document was published by the White House and sets forth guidance for all U.S. Government agencies to meet the specified national security priorities and objectives. The strategy describes the responsible use of taxpayer money to meet long-term goals and the need for “ a responsible budget that also depends upon working with our global partners and institutions to share burdens and leverage U.S. investment to achieve global goals. Our national security goals can only be reached if we make hard choices and work with international partners to share burdens .”

OPNAV Instruction 5440.75B Administration, Operation, and Logistic Support of T-AH 19 Mercy Class Hospital Ships (2010): This document was published by the Chief of Naval Operations and defines how hospital ships are organizationally structured in both full and reduced operating status as well as command relationships and responsibilities. The instruction states, “For secondary missions in support of disaster relief, humanitarian assistance, and DSCA, a technical contingent comprised of civilian and military personnel designated by the COCOM (possibly including foreign nationals, NGOs, etc.) may be embarked within the limitations of shipboard capabilities and appropriate USCF and MSC regulations.”

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Foreign Policy Advisors, where such appointments effectively advance our national interests…USAID will continue to appoint high-level development advisors to COCOMS where appropriate…and welcome the opportunity to detail mid to senior-level State and USAID personnel to COCOMs to improve working-level cooperation with the Department of Defense .” The QDDR describes the need to leverage the expertise of other interagency partners (e.g. DoD in context of counterterrorism capacity building and DHHS to build on existing relationships with ministries of health) which in the long-term “partnership with an building on the assets of other agencies will offer net policy gains to the U.S. government and reduce overall program implementation costs .” The document further claims, “ Multistakeholder efforts allow us to attract and focus significant resources and expertise on important policy priorities with relatively modest government seed money .”

Pacific Partnership 2010 Timor-Leste CONOPS Brief (Unclassified): This proposed Concept of Operations brief is provided by the U.S. Pacific Command to various participants and is identified as pre-decisional and pending Mission Commander approval. Implied tasks with partnership impact include “Generate list of SMEE topics in concert with HN MOH, Coordinate with Project Handclasp for mission integration, Coordinate with Project Handclasp for mission integration, Integrate operations with FFDTL and ISF.” The briefing provides a listing of partner nation military personnel taking part in the mission which includes the following: “Australia - 7 Medical Personnel, 15 Engineers, 1 Public Affairs Officer, 1 Photographer; Canada - 17 Medical Personnel; United Kingdom - 1 Medical Personnel; South Korea - 3 Medical Personnel; Portugal - 2 Medical Personnel. A list of NGO partners, number of participants, and their purpose during the mission is also provided: “International Relief Teams (6 PAX): Providing Medical Professionals; Latter Day Saints Charities (30 PAX): Will assist with MED/DENCAPs; Nour International/Islamic Relief Society America: Providing humanitarian supplies; Operation Smile (38 PAX): On board MERCY during the mission; Project Handclasp: Providing humanitarian supplies; Project Hope (25 PAX): Providing Medical Professionals; University of California San Diego Pre–Dental Society (59 PAX): Providing engineers, dentists, dental hygienists, and medical/dental assistants; Vets Without Borders (1 PAX): Providing veterinarian; World Vets/UWA (6 PAX): Providing veterinarians.”

U.S. DoD Pacific Partnership 2010 Post Deployment Brief (Unclassified): This briefing was presented by the Mission Commander and clearly stated PP10 enabled the U.S. Maritime Strategy with defining aspects related to partnership including: “ Conducted operations with Partner Nation ships and embarked record number of NGO volunteers (411) .” A slide depicting the partnerships for PP10 listed 6 host nations (Vietnam, Cambodia, Indonesia, Palau, Timor-Leste, Papua New Guinea), 10 partner nations (Australia, Canada, Cambodia, France, Japan, New Zealand, Portugal, Republic of Korea, Singapore, United Kingdom), and 19 NGOs (Civic Force, East Meets West, Hope Worldwide, HUMA, International Relief Teams, Islamic Relief Society America, Latter- day Saint Charities, Nour International, Operation Smile, Operation Unies, Peace Winds, American/Japan, Population Services International, Project Handclasp, Project Hope, St. John Ambulance, Surgical Eye Expeditions, UCSD Pre-Dental Society, Vets Without

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Borders, World Vets) and Interagency partners (Country Teams, USAID, US Public Health Service). Partnership between the hospital ship mission and Timor-Leste F- FDTL included: “PP10 transportation support brought F-FDTL to all MED/DENCAP sites (Medics, Communicators, and Translators); F-FDTL MED/DENCAP planned in the next 2-3 months; F-FDTL Engineers fully integrated into multilateral effort at Nu Laran ENCAP, completing one of six building renovations.”

U.S. DoD Pacific Partnership 2010 Post Deployment Brief (Unclassified): This briefing was presented by the Mission Commander and clearly stated PP10 enabled the U.S. Maritime Strategy with defining aspects related to partnership including: “ Conducted operations with Partner Nation ships and embarked record number of NGO volunteers (411) .” Although the number of partner nation participants was similar to previous hospital ship missions, the level of naval vessel contribution increased. In Timor-Leste, significant achievements related to partnerships included “integrated with Timor-Leste based personnel from ISF, UN, Australian DCP, and NMCB-11; Full integration of F- FDTL at RON and Dili sites; and Transferred $252K medical supplies to USAID.”

Distribution of Themes among Participants

Within Units of Analysis

251

Across Units of Analysis

Means for Testing

Triangulation

Data emerged from different sources to include the key stakeholder interviews and documentary review.

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

Theme emerged between units of analysis: Strategic, operational, and tactical levels.

Reliability/Internal Validity

Theme was mentioned in 32 sources and referenced 88 times.

Theme is considered a plausible element of the theoretical framework.

External Validity

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

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Appendix U. Theme: Increasing Visibility

Key Findings Summarized

This theme is a plausible element of generating impact as depicted in the theoretical framework (Figure 7) and featured in 15 key stakeholder interviews; in NGO, USG, and PN units of analysis; and across all levels of participation. It is interesting to note this theme was more prominent between both PNs (43.3%) and NGOs (37%) than USG (19.7%) participants. Additionally, HN partners did not describe increasing visibility during the key stakeholder interviews. Among the 30 references coded, operational participants (47.2%) most often cited this theme followed by tactical (34.9%) and strategic (17.9%) level participants. The frequency of reporting and prevalence within most and across all units of analysis provides reliability and internal/external validity to the theme of increasing visibility. The theme was triangulated during the documentary review where increasing visibility featured in 1 (8.3%) of guidance documents reviewed.

Evidence from Interviews

Within Units of Analysis

USG: Military

Military participants mentioned visibility being increased as a result of the hospital ship itself and being a mission participant. One participant stated, “It’s visible. Everybody knows what it is. Everyone knows what it does. It’s always in the pictures in the paper, you know. I mean, even if it’s anchored out, there’s a picture of it. So it’s something readily identifiable that’s rendering assistance.” Another mentioned, “These big events give us more visibility but we have continuing ongoing stuff, medical, engineering exercises and events. So it’s a recurring cycle that keeps us access with the government…it brings the larger NGOs with it, as well, so it gives them some visibility they may not have had here before.” Another senior level participant suggested in terms of HN visibility, ““It only matters when that four-star tells his staff, “Maybe we need to be a little less showy and we need to feature the local Mayor and local person because by making that Mayor or that Minister of Health look good, we strengthen that country by strengthening the support that the citizens have towards their government.””

USG: Non-Military

An increase in visibility of the partners among the host nation population was increased as a result of the hospital ship mission. A non-military participant with many years of experience working in Timor-Leste stated, “we did go up to some of the inland areas, delivered care there at one of their clinics up in the hills to people who really hadn’t had much in way of the American presence there providing healthcare before.” They went on to say, “the big white ship with the Red Cross is absolutely wonderful, and this is the business side of me speaking. It’s a wonderful marketing tool. When it pulls into a

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harbor, it’s quite visible and everybody knows that it’s there. And they, you know, if it comes pier side people flock there.”

PN: Pacific Region Presence

The mission increased the visibility of the partner nation participants in the host country by virtue of being associated with the hospital ship as well as the work the partners conducted in remote locations. One participant said, “a lot of the locals would just be standing staring out at the ocean at the Mercy because it really is quite an amazing looking ship and I think just by being there, it provides its whole subculture. It’s just this feeling that something good will happen.” Another said, “so if you look at it from the higher level between say, who was in charge in the Papua New Guinea area and obviously, who was in charge with the U.S. one, well, they would probably see it differently to the way I saw it. So when myself and the other nurses were out there in these islands, vaccinating people they saw us as (partner nation name deleted).”

PN: Non-Regional Presence

The hospital ship missions assisted the partner nation military in achieving their objective of showing support to the Pacific region. A senior level participant with experience in multiple missions said, “what we were looking for…from the political arena, you know, to wave the flag, to show that (partner nation name deleted) wants to remain an active participant in the Pacific region…Wave the flag and to show that (partner nation name deleted) is wanting to assist in providing support to the underserved populations in the South Pacific.”

HN – N/A

NGO: Long-Term Relationship

As stated above, the hospital ship missions increase the publicity and visibility of the long-term participating NGOs. However, some resentment in equal representation for unequal contribution was expressed. A participant with the experience of multiple missions said, “there’s a lot of NGOs that do participate and get their logo on the PowerPoint slide that are really just providing some supplies…or maybe like the Rotary Club, they maybe have in-country interpreters that aren’t necessarily deploying anywhere. They’re just already in-country or you’ve got all the way to the extent of multiple volunteers that are actually ship riding.”

NGO: Short-Term Relationship

The hospital ship mission supported the short-term NGO by increasing their visibility among the host nation population. An operational level participant said, “in Timor-Leste, (NGO name deleted) aren’t particularly well known so I suppose it’s definitely made an impact that people will maybe recognize it or remember sort of the logo or the people that helped them so I think definitely, you know, can only have done good.”

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NGO: Local-NGO

One local NGO served as a connector between the hospital ship mission and the Ministry of Health, which increased their visibility and respect. They said, “The Ministry is really like, they appreciate the support beyond their capacity and it was not in the (NGO name removed) plan. So when we present something that Ministry wants and we cannot provide, so it’s complementary, it’s like they, kind of the gift for the Ministry. So the Ministry at that time, they considered this implementing partner as very important partner because they can bridge between additional resource and the government. So it’s a good opportunity, I think, for any organization to connect with the external resource. So they honor. They respect us. They always value the partner, the implementing partner.”

Evidence from Documentary Review

Guidance:

Distribution of Themes among Participants

Within Units of Analysis

255

Across Units of Analysis

Means for Testing

Triangulation

Data emerged from different sources to include the key stakeholder interviews and documentary review.

Theme emerged within multiple units of analysis: USG, PN, and NGO.

Theme emerged between units of analysis: Strategic, operational, and tactical levels.

Reliability/Internal Validity

Theme was mentioned in 15 sources and referenced 30 times.

Theme is considered a plausible element of the theoretical framework.

External Validity

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

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Appendix V. Theme: Generating Innovation

Key Findings Summarized

This theme is a plausible element of the partnership generating action as depicted in the theoretical framework (Figure 7) and featured in 21 key stakeholder interviews, in all units of analysis and across all levels of participation (Appendix V). Generating innovation was equally represented between USG (41.9%) and NGO (37.7%) participant responses. PN and HN made up 17.4% and 3.0% respectively. Among the 21 references coded, operational participants (69.2%) overwhelmingly cited this theme followed by tactical (17.8%) and strategic (12.9%) level participants. The frequency of reporting and prevalence within most and across all units of analysis provides reliability and internal/external validity to the theme of generating innovation. The theme was triangulated during the documentary review where generating innovation featured in 2 (40%) policy and 6 (50%) guidance documents reviewed.

Evidence from Interviews

Within Units of Analysis

USG: Military

Innovation was generated before, during, and after the hospital ship missions. Instead of conducting independent missions, U.S. military personnel recognized the need to integrate with other partners’ ongoing efforts. One participant said, “Now the Australians have such a long-term commitment, so they have a lot of the training programs in place already so we tried dovetailing with that and tried to help support their programs.” During a construction projected associated with the hospital ship mission, another participant mentioned, “We had Australian engineers, SEABEES, and NGOs and the Timorese guys…each team had their own building, so each team was focusing on fixing their specific building and then supporting each other. So if the Timorese had something about their building that they needed a hand on, one of our guys would go over there and help them with that. And then if we needed something on one of our buildings that we were working on, they’d send some people over and do whatever needed to be done. They understood a lot of the context and stuff like that of these buildings. So that was some excellent, you know, the guy, the engineers out in the field working hand in hand, excellent level of partnership and training and experience.” A participant with experience on multiple missions reflected on ways to generate innovation among the partnership in the future by stating, ““I understand that we can’t put a medical planning group in every embassy in the world but I think if we want to do it right, we might even take a DOD medical planning group and say, “Hey, you know, Pacific Partnership 2012 is going to, or 2014 is going to go to these countries, let’s six months beforehand send this medical planning group to each of these host nations and they’ll be there six months early and then when the PDSS comes with the team, their job is to optimize the impact of the Pacific Partnership mission.” I think that that would be extremely helpful.””

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USG: Non-Military

A non-military U.S. government participant with many years of experience working in Timor-Leste described innovation among HN partners as a result of the hospital ship mission. They said, “A lot of people in Timor-Leste are very keen to do a good job but their understanding and experiences are very limited and so to see a big organization like U.S. military come in and do something efficiently and effectively provides an excellent model for them.”

PN: Pacific Region Presence

A tactical level participant with the experience of multiple hospital ship missions described how the experiences changed their perception of what their own military could provide within their region of influence. They said, “I’d love to see it evolve more in the future where maybe we could take on the whole leg ourselves and be given that responsibility.” Furthermore, “it makes me think in, not that I have much sway in our Defence Force but, you know, why can’t we, once we get a ship with a better capability, why we couldn’t just go through different parts of PNG and Indonesia like our neighbors and offer a similar thing. Obviously, not to the grand scale that the Mercy can but you could go and hold small clinics where you might do some cataract operations or do some dental work or just do something that you feel would be manageable.”

PN: Non-Regional Presence

Partner nation military personnel stated the hospital ship missions generated innovation among partners in determining who would be involved in subsequent missions and what role they would play. A senior level participant said, “every year that the planning process continued…more NGO participation was visibly seen. More people were coming to the planning meetings. More people were getting engaged but also host nation countries were being engaged and sending representatives to the planning conferences to have input into what type of services and where these services would be provided in their respective countries. Now when I look back there wasn’t any of that in 2008 and as we moved the yardstick and as the U.S. Navy built up their knowledge base of Pacific Partnership then you started to see more of these organizations coming to the planning meetings and getting engaged.” They also went on to say, “they’ve reached out to enormous nongovernmental organizations and I’ve seen that firsthand with the amount of NGOs that have now come forward to want to be part of these exercises and to actively put volunteers on it and not only human volunteers but gifts and resources and supply.”

HN: As a result of the hospital ship mission and host nation personnel gaining new perspectives, they start to think about how to address current challenges with existing resources and identify what additional resources might be necessary to achieve their goals. One participant said, “we see that a lot of cases, which is, how I say, the tertiary care, it’s care that is really easy to perform in the Mercy ship. And then after they do operation, after, post-operation when they send them back to the hospital…they also

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influence how the hospitals here start to thinking ahead. If we do all the operation, I mean, thinking of improving the postoperative facilities here. So it’s good things that happen.” An operational level participant with the experience of multiple hospital missions said, “because I think after that, one of the questions were, ‘Okay, we want to have some of these equipments, also. We want to also improve tertiary care in the hospital while at the same time still continue with primary healthcare professionally.”

NGO: Long-Term Relationship – N/A

NGO: Short-Term Relationship – N/A

NGO: Local-NGO

In order to address issues and concerns among NGO participants, the local NGOs innovated by setting ““up an NGO group to meet with one another and work out any differences, perceived or real, whether it’s favoritism or, you know, “Why do you get to do this and we can’t do that?” and other stuff, so and that got to be, I mean, it worked, it worked out good.””

Evidence from Documentary Review

Policy:

DoD Instruction 6000.16 Military Health Support to Stability Operations (2010): This document was published by the Under Secretary of Defense for Personnel and Readiness and identifies military health support for stability operations (referred to as medical stability operations) as a core U.S. military mission to be conducted throughout all phases of conflict and across the full spectrum of military operations. The Assistant Secretary of Defense for Health Affairs is assigned the responsibility to “implement a joint and combined MSO education and training program that promotes interoperability and information sharing with relevant U.S. Government departments and agencies, foreign governments and security forces, IOs, NGOs, and members of the private sector...Develop and provide opportunities for personnel from other U.S. Government departments and agencies, foreign governments, IOs, and NGOs to participate in DoD training related to MSOs and in non-DoD education and training programs relevant to health, including stability operations, security cooperation, humanitarian assistance, disaster response, irregular warfare, health diplomacy, and health sector capacity building…Develop measures of effectiveness that evaluate progress in achieving the MSO goals.”

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Combatant Commanders, and interagency partners, advance the development and implementation of measures of effectiveness for stability operations. Ensure the DoD measures correspond and support broader U.S. Government measures .”

Guidance:

Joint Publication 3-08: Interorganizational Coordination During Joint Operations (2011): This document was published by the Director of the Joint Staff and provides the Armed Forces joint doctrine for coordinating military operations with the interagency, IOs, NGOs, and the private sector. A key insight into how interagency partnerships are established is exemplified by the U.S. Special Operations Command special operations support team (SOST). These teams are composed of senior military officers assigned to numerous governmental agencies and organizations pursuant to the Interagency Partnership Program. The SOST work in a synergistic fashion with their interagency partners “to accomplish mutually assigned tasks in the President’s National Implementation Plan.” They complete the tasks by “working within the interagency community, leverage requirements in the IC, facilitate reporting, and process information requests.” Additionally, the publication describes the Joint Interagency Coordination Group (JIACG) as “an interagency staff group that establishes regular, timely, and collaborative working relationships between civilian and military operational planners” at the Combatant Commands. It states “ if augmented with other partners such as IGOs, NGOs, and/or multinational representatives, the JIACG…enhances the capability to collaborate with those organizations and the private sector .”

Joint Publication 3-29: Foreign Humanitarian Assistance (2009): This document was published by the Director of the Joint Staff and “provides joint doctrine for planning, executing, and assessing foreign humanitarian assistance operations.” An organization described in the publication with partnership impacts among U.S. Government interagency participants is the DoS Civilian Response Corps. This group of civilian federal employees will be trained and equipped to deploy in support of countries in crisis

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and provide reconstruction and stabilization services. The CRC is described as a “partnership of eight departments and agencies” which include DOS, USAID and DHHS.

U.S. DoD Pacific Partnership 2010 Post Deployment Brief (Unclassified): This briefing was presented by the Mission Commander and clearly stated PP10 enabled the U.S. Maritime Strategy with defining aspects related to partnership including: “ Conducted operations with Partner Nation ships and embarked record number of NGO volunteers (411) .” In the context of personnel lessons learned, the briefing suggests the mission was “victim of PP’s overall success in attracting PN and NGOs” which may have resulted in dissatisfaction among these participants who were not as engaged as desired or expected. The need to balance U.S. military personnel with other PN and NGOs to ensure optimal utilization was identified. Additionally, the challenge of utilizing unskilled humanitarians was identified and recommendation of designating a dedicated liaison officer from contingents >12 suggested.

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Distribution of Themes among Participants

Within Units of Analysis

Across Units of Analysis

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Means for Testing

Triangulation

Data emerged from different sources to include the key stakeholder interviews and documentary review.

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

Theme emerged between units of analysis: Strategic, operational, and tactical levels.

Reliability/Internal Validity

Theme was mentioned in 21 sources and referenced 42 times.

Theme is considered a plausible element of the theoretical framework.

External Validity

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

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Appendix W. Theme: Achieving Organization Objectives

Key Findings Summarized

This theme is a plausible element of the partnership generating action as depicted in the theoretical framework (Figure 7) and featured in 20 key stakeholder interviews, within all units of analysis, and across all levels of participation. Content coded as achieving parent organizational objectives featured most prominently among PN participant responses (36.8%). NGO, USG, and HN made up 30.5%, 28.5%, and 4.2% respectively. Among the 37 references coded, operational participants (48.3%) most often cited this theme followed by strategic (29.6%) and tactical level (22.1%) participants. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of achieving organizational goals. The theme was triangulated during the documentary review where achieving organization objectives featured in 1 (20%) policy and 7 (58.3%) guidance documents.

Evidence from Interviews

Within Units of Analysis

USG: Military – N/A

USG: Non-Military

The hospital ship mission was described as achieving the goals of displaying U.S. commitment, providing humanitarian assistance, and building Timor-Leste health capability. A senior level participant stated, “out of my three years of service in Timor- Leste the greatest display of U.S. commitment to Timor-Leste was manifested through the visit of the Mercy…Just the impact that we had on showing the flag and showing that Americans cared to the average citizen of Timor-Leste, including in some very remote areas of the country was exceptional, almost, well, it exceeded my expectations.” They also went on to say, “if the goal is to demonstrate the U.S. interest in providing humanitarian assistance to Timor-Leste, it’s a pretty effective way to do it.” Another senior level participant said, “With the military and also the political leadership of Timor, I think the presence of the Mercy was a very strong signal of the commitment of the United States to the partnership with Timor-Leste, in general, but especially on the or with the military between the two militaries but then also it was, again, a strong signal of the U.S. support for both the provision of humanitarian services but also the strengthening of Timorese health capabilities.”

PN: Pacific Region Presence – N/A

PN: Non-Regional Presence

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The hospital ship missions assisted the partner nation military in achieving their objective of showing their support to the Pacific region and increasing the capacity of their personnel. A senior level participant with experience in multiple missions said, “what we were looking for…from the political arena, you know, to wave the flag, to show that (partner nation name deleted) wants to remain an active participant in the Pacific region…Wave the flag and to show that (partner nation name deleted) is wanting to assist in providing support to the underserved populations in the South Pacific. Secondly, from a military perspective, we viewed these as a great opportunity to do some capacity building.” A tactical level participant described their nation as seeing “an opportunity to expose as many healthcare providers to this scenario. We just don’t get this scenario very often.”

HN: The hospital ship mission supported the Ministry of Health in achieving their organizational objectives. A senior level participant stated, “I want to grant that every citizen of Timor-Leste regardless where they live, those who live in the mountain, in the village, in the valley or in the city shall have the same quality of health assistance. So if you have this belief, this code, you always looking for every sources, every expertise, every assistant that come… those partners can fill the gaps for the Ministry because we don’t have enough capacity to fill it. And also to support the Ministry of Health, to bring the service close to the community, to make sure that the community access to the health service, that is very important for us, as well.”

NGO: Long-Term Relationship

The hospital ship missions assist the long-term NGOs in achieving their parent organization objectives of deploying volunteers internationally, increasing publicity, and gaining HA/DR training. A senior level participant said, “it’s provided us an effective platform to deploy civilian volunteers and (NGO name deleted) is a civilian health capacity, health education capacity organization in which volunteers are a central component of our mission. Deploying with these Navy or DOD sponsored missions provides us a way of deploying those volunteers internationally. Let’s face it, the DOD does perform the bulk of the planning, the logistical support. They provide the platform for global projection. All we have to do is show up. So they provide us a platform and a forum for international deployment of volunteers.” They went on to say, “The fact that a 1,000-bed, level three hospital shows up, you can’t buy that kind of publicity whether they doing anything meaningful or not. So the fact that we’re deploying on that platform, some of that positive press rubs off with us, as well, and our donor/sponsors.” An operational level participant with multiple mission experience also stated, “we’re trying to expand our volunteer program so having a venue, again, that’s safe, that we can put large numbers of people, relieves a lot of pressure on us because we’ve got venues to place people. So I mean, having a site, multiple sites like that is helpful. I think the training and the integration for disaster response because we do consider ourselves a disaster response organization as well and, to be quite honest, we wouldn’t at this point in the game be doing very many disaster responses if it wasn’t for our participation on DOD disasters.”

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NGO: Short-Term Relationship

The objectives of the short-term relationship NGO were achieved during the hospital ship mission and included reaching individuals in need and providing another venue for participation of medical volunteers. One participant said, “we want to reach as many people as possible and working with any other NGO or organization is always going to benefit the charity. We obviously want to help as many people, so if we can help them through somebody else, then I’m sure it will benefit us as a charity.” Another stated, “I think that it has given us another venue to provide humanitarian services that we, for our medical personnel that they might not otherwise have.”

NGO: Local-NGO

Local NGOs were able to promote their organization and gain access to a large portion of the host nation population as a result of the hospital ship mission. A participant with many years of experience in Timor-Leste said, “we are a charity organization and we have contributed a lot of health service in Timor-Leste and we want to promote our NGOs to other partners how to work together with other partners in the future.” A participant with many years of Pacific region experience said, “we all agreed the, well, if we could at least ensure that we’re providing some health promotion messages about all aspects of nutrition, you know, of family planning, all sorts. Well, then some of those people might actually, that message might last longer than the prescription that they’ve gone home with, yeah? But that’s a win-win because I wouldn’t have had access to all those people had the clinic not been there potentially.”

Evidence from Documentary Review

Policy:

DoD Directive 5100.46 Foreign Disaster Relief (FDR) (2012): This document was published by the Under Secretary of Defense for Policy and sets forth policy and responsibilities for FDR operations. Responsibilities assigned to the Assistant Secretary of Defense for Special Operations/Low-Intensity Conflict include Advising the Secretary of Defense on providing military resources in support of other partner organizations (e.g. military airlift to transport NGO, IO, foreign government relief supplies) to meet national security objectives is a responsibility tasked to the same individual.

Guidance:

DoD Quadrennial Defense Review (2010): This document was published by the Secretary of Defense and provides direction to reforming the DoDs current capabilities

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and requirements in order to meet future challenges. The document recognizes, “America’s power and influence are enhanced by sustaining a vibrant network of defense alliances and new partnerships, building cooperative approaches with key states, and maintaining interactions with important international institutions such as the United Nations .”

U.S. National Security Strategy (2010): This document was published by the White House and sets forth guidance for all U.S. Government agencies to meet the specified national security priorities and objectives. In the context of poverty and disease, the national strategy recognizes this global challenge and contents that “ if we recognize these challenges, embrace America’s responsibility to confront them with its partners, and forge new cooperative approaches to get others to join us in overcoming them, then the international order of a globalized age can better advance our interests and the common interests of nations and peoples everywhere .”

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their respective citizens, strengthen our alliances and partnerships, increase our ability to work together, and enhance military-NGO relationships. This is a partnership with Timor Leste and the organizations who share a common interest in maintaining a stable and secure Pacific region .”

Distribution of Themes among Participants

Within Units of Analysis

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Across Units of Analysis

Means for Testing

Triangulation

Data emerged from different sources to include the key stakeholder interviews and documentary review.

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

Theme emerged between units of analysis: Strategic, operational, and tactical levels.

Reliability/Internal Validity

Theme was mentioned in 20 sources and referenced 37 times.

Theme is considered a plausible element of the theoretical framework.

External Validity

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

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Appendix X. Theme: Developing Trust

Key Findings Summarized

This theme is a plausible element emerging from making connections as a result of the partnership and is depicted in the theoretical framework (Figure 7). Developing trust featured in 21 key stakeholder interviews, within all units of analysis, and across all levels of participation (Appendix X). Content coded as developing trust featured most prominently among USG participant responses (56.3%). NGO, HN, and PN made up 22.6%, 14.1%, and 6.9% respectively. Among the 43 references coded, operational participants (42.1%) most often cited this theme followed by strategic (31.8%) and tactical level (26.1%) participants. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of developing trust. The theme was triangulated during the documentary review where developing trust featured in 1 (20%) policy, 3 (58.3%) guidance, and 1 (20%) of planning/execution documents reviewed.

Evidence from Interviews

Within Units of Analysis

USG: Military

One military participant claimed the hospital ship mission “fostered relationships and it built trust.” Although not directly related to Timor-Leste, another participant with experience on two hospital ship missions stated, “it’s all these junior leaders, like the people I worked with in Vietnam at the provincial level, and then I had dinner with, and then I am friends with, and that I’ve worked side by side taking patients, care of patients with, those people five years from now they’ll be provincial leaders. Ten years from now, twenty years from now they’ll be national leaders. I think that’s where this program’s really going to benefit us in every country we’ve visited. So it builds trust with the lower level but those lower level are going to progress and they’re going to mature and they’re going to be the senior leaders.”

USG: Non-Military – N/A

PN: Pacific Region Presence

The hospital ship mission presented opportunities for partner nation military participants to build trust with the various partners both by a continued presence over multiple missions and exceptional performance while assigned. A tactical level participant with experience in multiple hospital ship missions said, “Well, my perception is that maybe the U.S. might have valued what we did in 2006 and wanted to offer us a bigger role, maybe they could see that the (country name deleted) wanted to be involved and we had some very good working health professionals who could be put on and maybe that’s why

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we were offered a bigger role in 2008. And then from there, it’s flowed on, they obviously trusted us with the last contingent…so I think that’s great that they valued us enough to give us that responsibility.” A strategic level participant stated, “for me to lead med-caps on the beach and I think that was the first time that a partner nation had been allowed such responsibility.”

PN: Non-Regional Presence – N/A

HN: In a post-conflict nation such as Timor-Leste, a trust deficit may exist between the military and civilian community. The hospital ship mission was described as bridging this gap and changing the way the civilian population looks at the military, primarily, the U.S. military. A senior level participant felt, “at the time, when you’re talking about the U.S. Mercy ship, we don’t thinking about the humanitarian, we’re just thinking the peace, you know, before maybe the war but once they arrive here you see the military and then they start to provide the assistance, you know. It’s making people feel good. I can imagine that this is a good way. I’m not say how that would be promised but I guess these visits like this will probably help in creating the peaceful environment. So people are not surprised and they’re not worried. Then many times people have the negative thinking, negative feeling, but some people are not providing these conception about the U.S. that big ships are for war.”

NGO: Long-Term Relationship

Long-term relationship NGOs suggested the hospital ship mission assists in developing trust between the partners, specifically the NGOs, U.S., and partner nations. They also highlighted the mission’s bridge gaps where current trust deficits may exist between the NGO and military communities. An operational level participant with the experience of multiple missions said, “the longer we do these, the four, at least the three, the partner nation, U.S. and NGO, I think those relationships continue to get stronger and maybe a lot more trust built between them all.” They acknowledged, “there is competition between NGOs and there is I’d say competition sometimes friction or whatever you want to call it between NGOs and the military, that’s one of the major reasons for these missions is to work through these issues, which get in the way of doing our job when we respond to disaster or humanitarian assistance operations.” They concluded by saying, ““it really builds a lot of confidence and respect and appreciation for what our military is doing. I mean, it does so both onboard and when you come home and tell people about it… people are saying, “What…we’re doing that, you know, that’s amazing. Why don’t we hear more about that?””

NGO: Short-Term Relationship

Trust was gained as a result of working with the host nations during the hospital ship mission as well as associating with other partners during the mission whom already had gained the trust of the host nation. A tactical level participant said, “I think they had better trust of us and a better picture of us after we left…that was true in every country

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that we went to.” They also stated, “They’ve got quite good links with Australia, haven’t they? So maybe us being with Australia made an impact of being more able to trust us.”

NGO: Local-NGO

There was a feeling of trust built between the U.S. and host nation population as a result of the hospital ship mission. A tactical level participant said, “they value it because they think that American, this kind of activities are really, it’s kindful (sic) and very friendly, say it’s part of the friendship. So there is no hidden mission.”

Evidence from Documentary Review

Policy:

DoD Instruction 2205.02 Humanitarian and Civic Assistance (HCA) Activities (2008): This document was published by the Under Secretary of Defense for Policy and outlines policy for the conduct of HCA activities. The Instruction states these “activities may “involve cooperation with host-nation military or paramilitary elements (to include the participation of third party organizations such as NGOs or private and/or voluntary groups) to establish trust and enhance relations with those entities.”

Guidance:

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U.S. Pacific Command Strategic Guidance (2012): This guidance message was last updated by outgoing PACOM Commander, Admiral Robert Willard, and an updated version approved by the current PACOM Commander, Admiral Locklear, could not be located. This guidance defined the PACOM mission as “ U.S. Pacific Command (USPACOM), together with other U.S. Government agencies, protects and defends the United States, its territories, Allies, and interests; alongside Allies and partners, promotes regional security and deters aggression; and, if deterrence fails, is prepared to respond to the full spectrum of military contingencies to restore Asia-Pacific stability and security .” The guidance outlines five focus areas, three of which mention partners, and two dedicated to partnerships. The latter include: 1) Strengthen and Advance Allies and Partnerships and 2) Develop the U.S.-India Strategic Partnership. In order to strengthen and advance allies and partnerships, the strategy list three ways to support this focus area: “1) Strengthen existing Alliances and leverage them to shape the environment for building multilateral relationships and a more effective presence; 2) Enhance Alliances and partnerships to build capacity over the full spectrum of military activities; and 3) Promote military professionalism and enhance interoperability among Allies and partners to build trust and increase multilateral effectiveness.”

Policy/Execution:

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Distribution of Themes among Participants

Within Units of Analysis

Across Units of Analysis

274

Means for Testing

Triangulation

Data emerged from different sources to include the key stakeholder interviews and documentary review.

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

Theme emerged between units of analysis: Strategic, operational, and tactical levels.

Reliability/Internal Validity

Theme was mentioned in 21 sources and referenced 43 times.

Theme is considered a plausible element of the theoretical framework.

External Validity

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

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Appendix Y. Theme: Increasing HN Capacity

Key Findings Summarized

This theme is a plausible element emerging from generating impacts as a result of the partnership and is depicted in the theoretical framework (Figure 7). Increasing HN capacity featured in 25 key stakeholder interviews, within all units of analysis (although marginally among the PNs), and across all levels of participation (marginally among tactical level) (Appendix Y). Content coded as increasing HN capacity featured most prominently among USG participant responses (57.7%). NGO, HN, and PN made up 28.6%, 12.5%, and 1.3% respectively. Among the 78 references coded, operational participants (67.6%) overwhelmingly cited this theme followed by strategic (25.7%) and tactical level (6.7%) participants. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of increasing HN capacity. The theme was triangulated during the documentary review where increasing HN capacity featured in 1 (20%) policy, 11 (91.7%) guidance, and 1 (20%) of planning/execution documents reviewed.

Evidence from Interviews

Within Units of Analysis

USG: Military

The hospital ship mission facilitated an increase in HN capacity through military-to- military efforts. One participant recalled, “getting those F-FDTL medics and engineers working side by side with us at the med-cap and end-caps, I think that was the best… one of the most important things they did at the hospital was go fix their hospital equipment, you know, and then some basic training.” Another participant describe an increase in knowledge among HN participants as a result of the mission by stating, “some of the things that it achieved that are very important are showing a workable model, potentially workable model to host country partnerships, which is really the Ministry of Health, and its own district services to provide better services to the population and to figure out new ways of reaching people and ways of reaching new people. A lot of people in Timor- Leste are very keen to do a good job but their understanding and experiences are very limited and so to see a big organization like U.S. military come in and do something efficiently and effectively provides an excellent model for them.” In terms the long run sustainability of capacity building efforts, a senior level participant stated, “I would like to think that that has some long-term impact, even if it’s just moves the needle one bump, that’s good, and if you keep moving the needle one bump, after twenty years you have a significant change and that, I don’t think any of these missions have an impact immediately. They might have a goodwill impact that lasts for about six months and then goes away but if, you know, over the long haul you keep having a significant revisit rate and you keep bringing them along, this, I’m just speaking the Timorese in particular here, then the better off you’re going to be. They’re going to be more self-sufficient.”

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USG: Non-Military

There was a modest sense of HN capacity building as a result of the partnership. A senior level non-military participant stated, “But I feel that we were able to successfully get the ministry’s involvement in the activities of the Mercy and its crew and I hope it wasn’t just in the area of administrator services that they saw our capabilities but hopefully also on the ground in the interaction between our doctors and Timorese doctors. Perhaps there was some transfer of skills or capabilities.”

PN: Pacific Region Presence

Partner nation military participants with a regional presence described increasing HN capacity as a factor influencing partnerships. Specifically, they described their ongoing training efforts in the country before, during, and after the hospital ship mission as well as their contributions in support of the hospital ship. One participant stated, “we were there for quite a while and taught all different sorts of things, everything from, you know, a bit of gynecology to how to use these pieces of equipment and all that sort of stuff.” A tactical level participant said, “we went ashore together and gave some presentations on oral hygiene and we all had input into that and, yeah, that was really good.”

PN: Non-Regional Presence – N/A

HN: The hospital ship mission was credited with increasing HN capacity through knowledge transfer and services rendered. A senior level participant described the organizational knowledge gained by one of their directors when they stated, “my small director of the health department is able just to work with the team there and to organize together. We’re talking about capacity building and then how to work with the others, partners…a very important thing is they come to provide some training for the staff is very important because if they give you the treatment it’s the same but if they give the knowledge, same information, same as for us, it’s very important issue.” They went on to describe the knowledge gained from the hospital ship mission in terms of resource management. A senior level participant said, “we have limitation of capacity, as well, limitation of resource, as well, even we have resource but also how we can look at the resource, organize the resource and also controlling the resource, as well, and it is very important here and then with mission from Navy is a part of shows our location and also shows resource and then also our location and also intervention how to fill the gaps…because we know that even we have a lot of international specialists here but we still have limitation of capacity in term of how to implement those services and also we think that from humanitarian service so we can get some skills, especially from those international specialists in the boat and then they can provide, left some skill to the Timorese health professional and also to increase their capacity as well and their knowledge of health service.” An operational level participant described the transfer of services and knowledge and the impact it had on increase capacity by saying, “they send a team to the district to fix the medical equipment, yeah, biomedical and also some

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technical support. They come to do the training to our health staff, how to do the first aid.”

NGO: Long-Term Relationship – N/A

NGO: Short-Term Relationship

Among short-term relationship NGO participants, there was a sense of increasing HN capacity through the exposure of new activities. A tactical level participant suggested, “I think if they don’t know any different, they’re not going to improve their healthcare system over there, are they? So it’s definitely going to build their knowledge and skills for future development and practice.”

NGO: Local-NGO

Although many local NGOs were critical about the ability of the hospital ship mission to increase HN capacity, they did highlight the cross training of host nation providers and medical maintenance/repair as having an impact. A participant with the experience of three hospital ship missions stated, “our teams are training one of the Timorese young doctors to do the simple clefts, so he then can go onboard the ship and get this extra experience, he’s did quite a large number.” They went on to say, “the only thing that has been successful for some individuals, a large number of individuals, not a small number and certainly the first, probably the second mission was an element of repair and maintenance of equipment, which was very useful. Subsequently, we have started developing our own capacity a little bit…they really filled the gap that existed here.”

Evidence from Documentary Review

Policy:

Guidance:

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partnerships with a growing number of nations… whose interests and viewpoints are merging into a common vision of freedom, stability, and prosperity.”

DoD Quadrennial Defense Review (2010): This document was published by the Secretary of Defense and provides direction to reforming the DoDs current capabilities and requirements in order to meet future challenges. To prevent and deter conflict, the QDR highlights the required integration of “ diplomacy, development, and defense, along with intelligence, law enforcement, and economic tools of statecraft, to help build the capacity of partners to maintain and promote stability. Such an approach also requires working closely with our allies and partners to leverage existing alliances and create conditions to advance common interests .” The document has a dedicated section entitled “Build the security capacity of partner states ” and emphasizes DoDs historical role in this effort.

U.S. National Security Strategy (2010): This document was published by the White House and sets forth guidance for all U.S. Government agencies to meet the specified national security priorities and objectives. Specifically directed at the DoD, the strategy states “ Our military will continue strengthening its capacity to partner with foreign counterparts, train and assist security forces, and pursue military-to-military ties with a broad range of governments .” Furthermore, the DoD will help “ our allies and partners build capacity to fulfill their responsibilities to contribute to regional and global security .” It posits through development we can “ position ourselves to better address key global challenges by growing the ranks of prosperous, capable, and democratic states that can be our partners in the decades ahead .”

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U.S. Assistance to Timor-Leste: Promoting Stability, Partnering or Progress (2009): This briefing was presented by the USAID Mission Timor-Leste during the Timor-Leste Development Partners’ Meeting held April 2-4, 2009. Stated objectives of U.S. Assistance to Timor-Leste included: 1) Enhanced Stability and Security, 2) Transparent and Accountable Democratic Governance, 3) Expanded Income-Generating and Employment Opportunities, and 4) Improved Health. Total USAID Assistance to Timor- Leste was $24.32 in 2009, the last year reported which was down $700K from the previous year. Thirty-two percent of the total was distributed to the Health sector. Results of Assistance to Enhance Stability and Security included a workshop in Honolulu

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“to support the development of Timor-Leste’s first national security policy…deployment of…Navy Seabees to rebuild schools and clinics…logistical support and training for military.” Stated results of assistance improving the health of the Timorese people included “USNS Mercy treated almost 10,000 patients and performed 270 complex surgeries” with a photo of the USNS Mercy in the Port of Dili featured prominently on this slide. On a slide entitled “Goodbye, Conflict; Welcome, Development” a key theme of partnership is listed. “ The U.S. Government is a strong partner of the Government of Timor-Leste in: strengthening democratic institutions, providing security and stability for its people, encouraging economic growth, and improving the health of the Timorese people .”

Timor-Leste Strategic Development Plan 2011-2030 (2011): This document, created in consultation with all industry sectors and ministries of the government, describes a 20 year plan to develop the nation of Timor-Leste and share these benefits across the nation. Within the security sector the plan states, “ Our donors and partners have made a significant contribution to the reconstruction of our security sector and will continue to play an important supporting role. This assistance will be coordinated and matched to our needs and priorities to ensure that it accords with our nation’s circumstances and context .” Targets in this sector by 2015 include “ The F-FDTL will be deployed in United Nations peacekeeping operations with training and logistics support from defence partners…Timor-Leste will have consolidated and strengthened our relationships with our regional and global partners and friends .” By 2030, “ The naval competent (sic) of the F-FDTL will be well trained with the necessary infrastructure to control and protect our territorial waters and participate as a full partner in international naval exercises .”

Strengthen Communities in the area of Health Through SISCa (Integrated Community Health Services) Implementation Guide: This guide outlines a new strategy implemented by the Minister of Health to integrate health services “from, with and to the community” in order to “strengthen our health sector.” In the guide, the Minister calls upon both international and local NGOs to synchronize their activities in the health sector with this overarching strategy. The strategy and intent to integrate and synchronize health services with the local community has direct implications for services rendered as part of hospital ship missions (e.g. MEDCAPs and DENTCAPs). Although partners and partnerships are only described in the strategy between local actors and the host nation population, the implied role of international actors that include hospital ship mission participants is to work with these internal partners to support their ongoing activities at the community level.

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discussions and exchange of ideas, other public health topics, and humanitarian concepts .”

Planning/Execution:

Distribution of Themes among Participants

Within Units of Analysis

282

Across Units of Analysis

Means for Testing

Triangulation

Data emerged from different sources to include the key stakeholder interviews and documentary review.

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

Theme emerged between units of analysis: Strategic, operational, and tactical levels.

Reliability/Internal Validity

Theme was mentioned in 25 sources and referenced 78 times.

Theme is considered a plausible element of the theoretical framework.

External Validity

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

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Appendix Z. Theme: Performing New Activities

Key Findings Summarized

This theme is a plausible element emerging from generating impacts as a result of the partnership and is depicted in the theoretical framework (Figure 7). Performing new activities featured in 23 key stakeholder interviews, within all units of analysis, and across all levels of participation. Of note, content coded as performing new activities featured most prominently among NGO participant responses (48.4%). USG, PN, and HN made up 24.6%, 22.7%, and 4.3% respectively. Among the 64 references coded, operational participants (56.7%) overwhelmingly cited this theme and was split evenly among strategic (22.1%) and tactical level (21.1%) participants. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of performing new activities. The theme was triangulated during the documentary review where performing new perspectives featured in 2 (40%) policy and 5 (41.7%) guidance documents reviewed.

Evidence from Interviews

Within Units of Analysis

USG: Military

A senior level military participant suggested the partnership has evolved to performing new activities that include capacity building. They said, ““what’s valuable there is that we went from a situation where this was all the benevolence of the United States, you know. “Look what great things we can do,” just like Lewis and Clark, you know, giving trinkets to the Indians. And there has been an evolution and…you’ll see that now there is capacity building that is built into the planning.””

USG: Non-Military – N/A

PN: Pacific Region Presence

Partner nation military participants described the new activities they learned as a result of the hospital ship mission and how they use the experience to train personnel from their own military. One participant described the benefit as, “it’s something that we don’t typically do, we’re not as large as the American military, not even close, but so when we get invited to those things, we get the opportunity to work with other nations like at peace time. So we kind of get used to other people and doing things differently and an opportunity or in a situation where it’s easy to learn, like it’s not a stressful situation so I think we get to learn all kinds of new things and experience stuff that we don’t typically get a chance to do.” Another participant stated, “I think there will always be some people who will come back and do things the way they’ve always been done but I think still

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there’s some people, when they learn something new, a better way to do it, and then they come home and they teach other people.”

PN: Non-Regional Presence – N/A

The hospital ship mission provides new activities for partner nation military personnel and the partnership itself has also adapted as previously mentioned by “more of these organizations (NGOs, PNs, HNs) coming to the planning meetings and getting engaged with the Navy.” In the context of the partner nation military participants performing new activities, a senior level participant said “it’s exciting for the younger soldiers because they’re getting out of the clinics. They’re working in very austere environments…with partner nations…in a joint environment and the exposure is probably the single greatest takeaway from our participation in these exercises.”

HN – N/A

NGO: Long-Term Relationship

The NGO partners leveraged the morning report briefing as a new activity to allow equitable representation and participation among the NGO actors. An operational level participant recalled, “the CO gave the NGOs one spot on the morning report that the CO holds for the NGO folks to go to. So we would rotate that between us so that was equal. So one didn’t seem to have more presence or more favoritism or so because if you go to a meeting, you talk, you meet people, you do have some competition. So we would rotate that and then we would come back to the NGO group and we would then share that information, whatever people got, and I mean there are other ways to do it and then we would meet regularly in that way to kind of keep our heads together.”

NGO: Short-Term Relationship – N/A

NGO: Local-NGO

Although the local NGOs performed new activities, they were not linked to ongoing efforts. An operational level participant recalled, “I would describe my NGO’s activities to be very distinct with the Mercy ship from our activities in Timor. And that’s a shame because really they should be part of the same mission, part of the same thing.”

Evidence from Documentary Review

Policy:

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Defense for Health Affairs is assigned the responsibility to “implement a joint and combined MSO education and training program that promotes interoperability and information sharing with relevant U.S. Government departments and agencies, foreign governments and security forces, IOs, NGOs, and members of the private sector...Develop and provide opportunities for personnel from other U.S. Government departments and agencies, foreign governments, IOs, and NGOs to participate in DoD training related to MSOs and in non-DoD education and training programs relevant to health, including stability operations, security cooperation, humanitarian assistance, disaster response, irregular warfare, health diplomacy, and health sector capacity building…Develop measures of effectiveness that evaluate progress in achieving the MSO goals.”

DoD Instruction 3000.05 Stability Operations (2009): This document was published by the Under Secretary of Defense for Policy and reissued the DoD Directive Military Support for Stabilization, Security, Transition, and Reconstruction (SSTR) Operations as a DoD Instruction. Specific responsibilities include the Under Secretary of Defense for Personnel and Readiness is assigned the responsibility to “develop policy and opportunities for personnel from other U.S. Government agencies, foreign governments, international organizations, and nongovernmental organizations to participate, as appropriate, in DoD training related to stability operations.”

Guidance:

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HN populace, NGOs, and IGOs on a geographic basis .” The composition as described does not include the hospital ship humanitarian assistance mission partners into the CMOC organizational structure although latitude for interpretation exists since the document state the structure “must be tailored for each emergency.” The publication compares the function and composition of the CMOC to the UN Humanitarian Operations Center and Combatant Commander Humanitarian Assistance Coordination Center.

Timor-Leste Strategic Development Plan 2011-2030 (2011): This document, created in consultation with all industry sectors and ministries of the government, describes a 20 year plan to develop the nation of Timor-Leste and share these benefits across the nation. Highlighting the success of the Referendum Package established in 2009 to establishing a partnership between the private sector and local government to fast-track rural development. This included “ encouraged strategic partnerships between the private sector and the government in urban and rural areas in the construction of over 800 small to medium size infrastructure projects. The initiative injected funds directly to community based companies for building and infrastructure projects to stimulate local economies, create direct and indirect employment opportunities, identify and mobilize the local skills base, and give communities the opportunity to participate in nation building .”

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operations with Partner Nation ships and embarked record number of NGO volunteers (411) .” Two key staff augmentees were identified as being invaluable resources during the mission: the Civil-Military Liaison Officer and the DoS Foreign Service Liaison Officer. The former served as the “single embarked Liaison for large number of PN and NGO personnel” and the latter “provided access to the Embassy.” It was suggested to facilitate interagency efforts, “Future FSLOs should work to develop USAID contacts in advance to assist with this aspect.”

Distribution of Themes among Participants

Within Units of Analysis

288

Across Units of Analysis

Means for Testing

Triangulation

Data emerged from different sources to include the key stakeholder interviews and documentary review.

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

Theme emerged between units of analysis: Strategic, operational, and tactical levels.

Reliability/Internal Validity

Theme was mentioned in 23 sources and referenced 64 times.

Theme is considered a plausible element of the theoretical framework.

External Validity

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

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Appendix AA. Theme: Opening Dialogue

Key Findings Summarized

This theme is a plausible element emerging from building connections and is depicted in the theoretical framework (Figure 7). Opening dialogue featured in 25 key stakeholder interviews, within all units of analysis, and across all levels of participation. Content coded as opening dialogue featured prominently between USG (45.4%) and NGO (34.8%) participant responses. PN and HN made up 16.5% and 3.4% respectively. Among the 46 references coded, operational participants (46.2%) overwhelmingly cited this theme and were split evenly among tactical (28.5%) and strategic level (25.3%) participants. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of opening dialogue. The theme was triangulated during the documentary review where opening dialogue featured in 3 (60%) policy and 1 (8.3%) guidance documents reviewed.

Evidence from Interviews

Within Units of Analysis

USG: Military

The relationship between hospital ship mission partners facilitated the opening dialogue with non-participating organizations. One study participant stated, “the Australian, the Task Force they brought us all over the country…they introduced us to local leaders and they were very helpful.” Dialogue was also opened between individual participants at senior levels that influenced working relationships between participants. One example was when a senior military participant ““met with the Ambassador he said, you know, “We don’t have a laboratory that can test water for water purification in Timor and it would be really great if you guys could help us.”” The military team “put a program together and met with them at their equivalent, worked with the World Health Organization that was in-country and provided, I was there when we did the brief to the Minister of Environmental, I can’t remember what it was called, the Environmental Health and Sanitation.” The mission also facilitated opening a dialogue with participants who had no prior interaction. A senior level participant commented, “our mission was the first mission of the Japanese JSDF working with NGOs, Japanese NGOs. And…when you talk to them, it was invaluable in making those connections between NGOs and the JSDF. So when it came time to respond to the tsunami, they could do that.”

USG: Non-Military

A senior level U.S. government participant attributed ongoing U.S. military support to Timor-Leste as a result of a dialogue started during the hospital ship mission. “Admiral Willard was also essential in the support the U.S. provided at the Center for, Asia Pacific

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Center for Security Studies that helped the Timorese develop for the first time a national security strategy. Admiral Willard was also a very strong supporter of the establishment of regular joint training exercises between the U.S. Marines and the Timorese military, another set of those exercises is, is just about to start again. I really credit Admiral Willard and his support for a lot of the very positive work that the United States was able to launch during my tenure…that was only possible because he saw the opportunities that existed for increased interaction between our two militaries and this was a major positive side effect of the Mercy’s visit to Timor.”

PN: Pacific Region Presence – N/A

PN: Non-Regional Presence

The hospital ship mission presented opportunities for the partner nation military participants with a non-regional presence to open a dialogue with other partners including the U.S. and other militaries as well as NGOs. It also opened a dialogue with host nation translators, although not a predefined “partner” to the mission, in which both sides learned from each other. Specifically, an operational level participant with the experience of multiple missions stated, “I think it’s just working together and at times, we did chime in with Americans and some Aussies, small amounts of Japan, so just working together and seeing some of the inter-operability that we can work together and meet a common goal.” They went on to say, “From my experience at the planning conferences, they treat us well. They value our input but like I said earlier when it comes to the execution we just sort of stand back and they do what they want to do and I understand because eventually, ultimately, it’s your mission and we are just a mechanism to assist in meeting that goal.” A tactical level participant observed the NGOs collaborating and stated “so there wasn’t just this one NGO over here doing this, one NGO over there. They were actually talking to each other, helping each other out and, yeah, it was fantastic.” Another tactical level participant described the dialogue generated during the mission with translators. They said, “translators come from the host nations and we got along quite nicely…They were quite proud of the countries and they were quite free to tell us all about their countries and what was going on and so some good friendships.”

HN: The hospital ship mission facilitated a dialogue between the Ministry of Health and mission participants. The mission also reinforced an existing dialogue between national, district, and sub-district Ministry of Health personnel. A senior level participant stated, “I…meet with some of the delegation and then…open the discussion how to make the operation successful.” They went on to say, “sending the advanced team, which is good. They have a very good office here, you know. And the advanced team is not civilian. The military is coming. So it’s very good. When they arrive they always send one of the military officers and then doctors come to talk.” An operational level participant stated, “we have the coordination meetings with U.S. Navy mission and also sit together with them, establish the agenda, and also to find the appropriate area so the mission can go there and also coordinate with the target area or the mission area for Ministry of Health side and inform to the director of the district and also the sub-district, informing about the

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activities and then coordinate with the district and sub-district level, how we can prepare their self and also to prepare the community mobilization, as well, so they mobilize the community and then also make sure that when the missions arrive in their district or sub- district the cooperation already there and then waiting for the mission and also to receive humanitarian assistance from their mission.”

NGO: Long-Term Relationship – N/A

NGO: Short-Term Relationship – N/A

NGO: Local-NGO

The hospital ship mission created an opportunity for the local NGOs to open a dialogue on a unique topic with the host nation that may have not previously existed. An operational level participant said, ““I think as partners and as guests in this country, in a sense, the onus is on us to sell the idea, not just expect people to say, “Oh, it’s amazing, there’s a big ship coming with loads of operating theaters,” you know. That can sound really wow factor for us but that doesn’t actually mean it’s a wow factor for everybody.””

Evidence from Documentary Review

Policy:

DoD Directive 5100.46 Foreign Disaster Relief (FDR) (2012): This document was published by the Under Secretary of Defense for Policy and sets forth policy and responsibilities for FDR operations. Responsibilities assigned to the Assistant Secretary of Defense for Special Operations/Low-Intensity Conflict include “coordinate DoD FDR operations and policies with USAID, the Department of State, and other involved Federal departments and agencies; promote FDR collaboration among these departments and agencies. Represent the Secretary of Defense…in discussions on FDR policy, strategy, and operations with other U.S. departments and agencies, including USAID, and with foreign governments, international organizations (IOs), non-governmental organizations (NGOs), and members of the private sector.”

DoD Instruction 3000.05 Stability Operations (2009): This document was published by the Under Secretary of Defense for Policy and reissued the DoD Directive Military Support for Stabilization, Security, Transition, and Reconstruction (SSTR) Operations as a DoD Instruction. The Assistant Secretary of Defense for Special Operations and Low- Intensity Conflict and Interdependent Capabilities is tasked “in coordination with the Chairman of the Joint Chiefs of Staff, lead DoD contributions to developing common doctrine, policies, and procedures for stability operations activities with other Government agencies and international partners .”

National Security Presidential Directive-44 (NSPD-44) on Management of Interagency Efforts Concerning Reconstruction and Stabilization (2005): This directive was

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published by The White House “to promote the security of the United States through improved coordination, planning, and implementation for reconstruction and stabilization assistance for foreign states and regions at risk of, in, or in transition from conflict or civil strife.” This document states, “The Secretary of State shall coordinate such efforts with the Secretary of Defense to ensure harmonization with any planned or ongoing U.S. military operations across the spectrum of conflict.” The Coordinator for Reconstruction and Stabilization within the Department of State will assist the Secretary to “coordinate reconstruction and stabilization activities and preventative strategies with foreign countries, international and regional organizations, nongovernmental organizations, and private sector entities with capabilities that can contribute…Develop strategies to build partnership security capacity abroad and seek to maximize nongovernmental and international resources …”

Guidance:

Joint Publication 3-08: Interorganizational Coordination During Joint Operations (2011): This document was published by the Director of the Joint Staff and provides the Armed Forces joint doctrine for coordinating military operations with the interagency, IOs, NGOs, and the private sector. The publication addressed the sharing of information between multinational partners by stating, “information should be written for release at the lowest possible classification level and given the fewest possible dissemination restrictions within foreign disclosure guidelines.” Furthermore, “ establishment of direct communications between commanders, interagency partners, NGOs, IGOs, indigenous populations and institutions, and the private sector facilitates effective coordination and decision making .” The publication states, “Civil Military Operations, through establishing and maintaining communications, is one of the best ways to unify military and public and private partnerships and best practices to improve the HN’s internal security and promote stability operations in the operational area.”

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Distribution of Themes among Participants

Within Units of Analysis

Across Units of Analysis

294

Means for Testing

Triangulation

Data emerged from different sources to include the key stakeholder interviews and documentary review.

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

Theme emerged between units of analysis: Strategic, operational, and tactical levels.

Reliability/Internal Validity

Theme was mentioned in 25 sources and referenced 46 times.

Theme is considered a plausible element of the theoretical framework.

External Validity

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

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Appendix BB. Theme: Understanding Partner Constraints

Key Findings Summarized

This theme is a plausible element of learning through the partnership and is depicted in the theoretical framework (Figure 7). Understanding partner constraints featured in 29 key stakeholder interviews, within all units of analysis, and across all levels of participation. Content coded as understanding partner constraints featured prominently between USG (52%) and NGO (33.1%) participant responses. PN and HN made up 9.5% and 5.4% respectively. Among the 90 references coded, operational participants (56.7%) overwhelmingly cited this theme and were split evenly among strategic (22%) and tactical level (21.3%) participants. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of understanding partner constraints. The theme was triangulated during the documentary review where understanding partner constraints featured in 1 (20%) policy and 4 (33.3%) guidance documents reviewed.

Evidence from Interviews

Within Units of Analysis

USG: Military

Military participants felt the lack of military medical personnel assigned to the U.S. Embassy in country as an internal constraint to the partnership. One participant stated, “The Pacific Partnership would be more effective if all our embassies, our in-country military groups had more of a plan, but they don’t have medical assets assigned to them.” Another constraint identified was the inability of the military to track individuals with the partnership experience. This was described by one when they mentioned, ““One of the things we talked about in our after-action brief was the need to find ways to identify personnel in their records that have done these kinds of missions before, so that way if a natural disaster occurs in Timor-Leste, we say, “Hey, look, these are the people who have worked in that country on humanitarian projects before, let’s pull them from their various commands and send them to lead the project or the response.”” The inability of the partnership to align with NGOs currently serving in Timor-Leste was described as an internal constraint. An experienced participant stated, “we really have to do to do a better job in Timor is align with the in-country NGOs.”

USG: Non-Military

Non-military participants gained a better understanding of host nation and U.S. government participant constraints as a result of the hospital ship mission. An operational level participant stated, ““it was quite a challenge in Timor to get the host government to really see themselves as equal partners in this mission, and that was generally true with both Pacific Partnerships. But that’s, I think not due to a lack of

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willingness on their part but more to general lack of capacity.” The constraint among U.S. government partners in Timor-Leste was described by one participant when they said, “And given we have a military person on the ground and we rarely interact. He doesn’t come to (organization name deleted). He doesn’t engage on an ongoing basis any of our (word deleted for confidentiality) programs and what we’re doing. So there’s no real sense of understanding, so, I think that if that sort of partnership needs to be more in place and if you don’t have that at the country level that you’re in then you can’t expect something, a ship to just come in for ten days and expect it to harvest an ongoing partnership.”

PN: Pacific Region Presence – N/A

PN: Non-Regional Presence

The hospital ship mission brought together the various partners during planning conferences where constraints were identified and solutions to shortfalls developed. One senior participant said, “we got involved at the initial planning conferences where we… would sit down and basically listen to determine where the shortfalls were, or the tasking pressures where the U.S. Navy or other DOD organizations were having when it came to the request for forces that were going to deploy on the exercise.” Constraints of their own were identified and filled by other partners as seen when “each partner nation had a Public Affairs representative on the ship, less (partner nation name deleted), and that’s why the Australian Major took up (partner nation name deleted) cause.”

HN – Participants acknowledge the constraints of their own Ministry of Health in terms of the partnership and not those of other partners.

NGO: Long-Term Relationship – N/A

NGO: Short-Term Relationship

The short-term participating NGO gained a better understanding of the host nation constraints and potential impact they would have on building an equitable partnership. A tactical level participant said, “I think, in order to have a true partnership you would need equal standards. Obviously these countries don’t have the medical provision I assume that the U.S. has…So I think there wasn’t a huge amount of medical people there to share information with.”

NGO: Local-NGO

The local NGOs were able to gain a better understanding of partner constraints as a result of the hospital ship mission. In particular, the U.S. constraint in taking on more complicated patients was a theme expressed by many as well as the fact no single local NGO has complete coverage of Timor-Leste and collaboration would be necessary to achieve the mission objectives. A participant with many years of experience in the Pacific region said, “you’re having interesting conversations because, of course, things

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that were raised were issues around post-operative care, the actual just general follow up. And so those were interesting discussions but, of course, it wasn’t that they weren’t answered but, the ship’s not designed to be a mission that provides post-operative care. And so then by definition, it can’t take on the most complicated operations because those types of operations would probably require the most follow up. So in which case you’re then looking at some of the cases and I’m thinking particularly of say cleft palate ops, that we’re already capable of dealing with here or with our proximity to Australia, we have regular teams that come over. So then you’re, inadvertently, in a sense, raise expectations and hope that finally some of the poor people who have been living with extraordinary either disfigurement, for example, may get treatment and then, of course, they can’t because their condition is too severe. And that’s not the Mercy ship’s fault, but I suppose that realization comes about when you then have the meetings to discuss the types of services it can provide and the post-op follow up. And then it seems awfully tense, you know.” They also went on to say, “However unsustainable that system is and it’s not designed to be sustainable, so, if the Mercy ship is going to kind of continue missions like that, it would be foolish to not try and maximize that.” Another participant with numerous years of NGO experience in Timor-Leste said, “as implementing partners between us all, no partner covers thirteen districts but between us all, you’ve got the country covered.”

Evidence from Documentary Review

Policy:

DoD Instruction 3000.05 Stability Operations (2009): This document was published by the Under Secretary of Defense for Policy and reissued the DoD Directive Military Support for Stabilization, Security, Transition, and Reconstruction (SSTR) Operations as a DoD Instruction. The document states DoD will lead these types of operations to “establish civil security and civil control, restore essential services, repair and protect critical infrastructure, and deliver humanitarian assistance until such time as it is feasible to transition lead responsibility to other U.S. Government agencies, foreign governments and security forces, or international governmental organizations.”

Guidance:

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innovative and creative solutions to maintain our support for allied and partner interoperability and building partner capacity .”

DoD Quadrennial Defense Review (2010): This document was published by the Secretary of Defense and provides direction to reforming the DoDs current capabilities and requirements in order to meet future challenges. Underpinning future resource constraints, the QDR highlights “ The U.S. will work with our allies and partners to effectively use limited resources by generating efficiencies and synergies from each other’s portfolios of military capabilities, thereby enhancing our collective abilities to solve global security problems .”

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Distribution of Themes among Participants

Within Units of Analysis

Across Units of Analysis

300

Means for Testing

Triangulation

Data emerged from different sources to include the key stakeholder interviews and documentary review.

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

Theme emerged between units of analysis: Strategic, operational, and tactical levels.

Reliability/Internal Validity

Theme was mentioned in 29 sources and referenced 90 times.

Theme is considered a plausible element of the theoretical framework.

External Validity

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

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Appendix CC. Theme: Understanding Partner Agenda

Key Findings Summarized

This theme is a plausible element of learning through the partnership and is depicted in the theoretical framework (Figure 7). Understanding partner agenda featured in 23 key stakeholder interviews, within all units of analysis, and across all levels of participation. Content coded as understanding partner agenda featured prominently among USG (57.2%) participant responses. NGO, PN and HN made up 26.8%, 12.6%, and 3.5% respectively. Among the 59 references coded, operational participants (55.8%) overwhelmingly cited this theme. Strategic (30.2%) and tactical level (14%) participants made the remaining references during the key stakeholder interviews. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of understanding partner agenda. The theme was triangulated during the documentary review where understanding partner agenda featured in 3 (60%) policy, 3 (25%) guidance, and 1 (20%) planning/execution document.

Evidence from Interviews

Within Units of Analysis

USG: Military

Military participants gained a better understanding of the various partner agendas as a result of the hospital ship mission. This included the partner nations, “the Australians and, and New Zealand, they’re very active in the region and so by having them on the ship with us, this then allowed them to kind of do their own thing that they needed to do.” This also included gaining a better understanding of the NGO agenda as reflected by another when they said, “It is really a complicated issue, there’s a little bit of a dirty side to it, all the fundraising. You kind of get a little disillusioned but it is a business. And working that whole aspect in, when you see Project Hope and you see kids with cleft palates…they put out what it takes to get money to support and grow…They want to be the best NGO, just like all the other ones.” A senior level military participant also felt an understanding was achieved between USG participants as a result of the hospital ship mission. They said, “I think the other thing is that I felt like the embassies were starting to use us.”

USG: Non-Military

Although not a stated goal of the hospital ship mission among U. S. military participants, the perception of one non-military participant is that the mission “was an opportunity for them to deploy additional resources to Timor-Leste in a big, splashy way and I think they were happy to do so.”

PN: Pacific Region Presence – N/A

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PN: Non-Regional Presence

Partner nation military participants identified what they perceived to be the mission goal/agenda and adapted to support the partnership success. They also recognized each partner organization has an agenda and credited the leadership in synchronizing their effort to achieve the overarching hospital ship mission goals. A tactical level participant said, ““The goal was to try to deliver some healthcare knowing that weren’t delivering total healthcare all to everybody all the time. We weren’t their family physicians. So that I found difficult and but adapted.” They also stated, ““these groups have agendas and they want what they want to push but I think the leadership there was pretty good about saying, “these are our goals and these are our objectives,” and try to, you know, corral us working in a sandbox, so we had some leeway but we had general guidelines to go by.”’

HN – A strategic level participant said, “we have, how you call it, the coordination meetings with U.S. Navy mission, as well, and also sit together with them, establish the agenda, as well.”

NGO: Long-Term Relationship – N/A

NGO: Short-Term Relationship – N/A

NGO: Local-NGO

Local NGOs gained a better understanding of partner agendas as a result of the hospital ship mission. One participant said, “A number of months before both ships arrived there were meetings held at either the U.S. Embassy or USAID…It was an opportunity to learn more about some of the services that would be available and also for us to give, I think, some advice as organizations who are established in-country as to how best to kind of maximize the opportunity of having a hospital ship.”

Evidence from Documentary Review

Policy:

DoD Instruction 3000.05 Stability Operations (2009): This document was published by the Under Secretary of Defense for Policy and reissued the DoD Directive Military Support for Stabilization, Security, Transition, and Reconstruction (SSTR) Operations as a DoD Instruction. Recognizing the role of both the civilian and military sectors in stability operations, the Instruction states the “Department shall collaborate with other U.S. Government agencies and with foreign governments and security forces, international governmental organizations, nongovernmental organizations, and private sector firms as appropriate to plan, prepare for, and conduct stability operations.”

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DoD Instruction 2205.02 Humanitarian and Civic Assistance (HCA) Activities (2008): This document was published by the Under Secretary of Defense for Policy and outlines policy for the conduct of HCA activities. The Instruction states “HCA shall be conducted with the approval of the host nation’s national and local civilian authorities…compliment, not duplicate, other forms of social or economic assistance provided to the host nation by other U.S. Departments of Agencies…Require Secretary of State or designee approval.” The Commanders of the Combatant Commands are directed to “Ensure HCA activities are conducted with the approval of the Secretary of State through the appropriate U.S. Chief of Mission and obtain any required diplomatic notes, temporary status of forces agreements, and/or memorandums of agreement required to conduct HCA activities.”

National Security Presidential Directive-44 (NSPD-44) on Management of Interagency Efforts Concerning Reconstruction and Stabilization (2005): This directive was published by The White House “to promote the security of the United States through improved coordination, planning, and implementation for reconstruction and stabilization assistance for foreign states and regions at risk of, in, or in transition from conflict or civil strife.” This document states the Coordinator for Reconstruction and Stabilization within the Department of State will assist the Secretary to “coordinate reconstruction and stabilization activities and preventative strategies with foreign countries, international and regional organizations, nongovernmental organizations, and private sector entities with capabilities that can contribute…Develop strategies to build partnership security capacity abroad and seek to maximize nongovernmental and international resources …”

Guidance:

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U.S. National Security Strategy (2010): This document was published by the White House and sets forth guidance for all U.S. Government agencies to meet the specified national security priorities and objectives. It acknowledges “ the U.S. and our allies and partners may sometimes disagree on specific issues, we will act based upon mutual respect and in a manner that continues to strengthen an international order that benefits all responsible international actors .”

Planning/Execution:

Distribution of Themes among Participants

Within Units of Analysis

305

Across Units of Analysis

Means for Testing

Triangulation

Data emerged from different sources to include the key stakeholder interviews and documentary review.

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

Theme emerged between units of analysis: Strategic, operational, and tactical levels.

Reliability/Internal Validity

Theme was mentioned in 23 sources and referenced 59 times.

Theme is considered a plausible element of the theoretical framework.

External Validity

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

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Appendix DD. Theme: Understanding HN Needs

Key Findings Summarized

This theme is a plausible element of learning through the partnership and is depicted in the theoretical framework (Figure 7). Understanding HN needs featured in 25 key stakeholder interviews, within all units of analysis (although at a lower level in PN participants), and across all levels of participation. Content coded as understanding HN needs featured prominently among USG (61.6%) participant responses. NGO, PN and HN made up 24.7%, 7.8%, and 5.9% respectively. Among the 63 references coded, operational participants (50.6%) overwhelmingly cited this theme. Strategic (28.8 %) and tactical level (20.6%) participants made the remaining references during the key stakeholder interviews. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of understanding HN needs. The theme was triangulated during the documentary review where understanding HN needs featured in 4 (80%) policy documents.

Evidence from Interviews

Within Units of Analysis

USG: Military

Military participants felt the hospital ship mission planning efforts facilitated a better understanding of the Timor-Leste needs. A member of a hospital ship mission pre- deployment site survey team stated, “part of our Advance Party’s work was to work with the Ministry of Health to identify potential surgical cases who we prescreened on our first day in port on, ashore.” Working in the host nation as part of the mission also led military participants to understand the HN capabilities and potentially shape future requirements of the partnership. A participant stated, “There’s frankly enough, their medical system, the national, the Ministry of Health is developing enough. Their national hospital system is developing to the point where the real serious surgeries and things like that they can actually handle a lot of those themselves.”

USG: Non-Military – N/A

PN: Pacific Region Presence – N/A

PN: Non-Regional Presence

At the tactical level, individuals were able to gain a better understanding of the HN needs. One participant reflected and said, “you’ll never see this very much again, if ever and it’s a great experience, working with the humanitarian mission and it’s a good experience working with host nations or with partnerships, just to get an idea where they’re coming from.”

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HN – Participants representing the Ministry of Health identified the needs of the Timorese people and what their organization, as well as the hospital ship mission, could support.

NGO: Long-Term Relationship

The hospital ship mission facilitated an understanding of the HN needs and the development of new perspectives on how to address them. An operational level participant providing health service support said, “This is Third World and so you can’t really apply your same, I mean, you’d like to say, give people the same quality of care but you really have to, that’s not the right way to say it but I don’t want to say, “Dumb down your medicine,” but, you have to put it at a more basic level. So, the partners that you work with over there, the host nation people, they help you to understand that and you have to be careful not to say, “Oh, my God, how can you do that?”

NGO: Short-Term Relationship

As a result of providing health services to the host nation population during the hospital ship mission, the short-term NGOs gained a better understanding of the HN needs. One participant said, “I remember in particular there was a child with quite a heart murmur, so we, obviously, couldn’t do anything for that patient but we did take their details and then, you know, formed a list of patients that would need more urgent care that we couldn’t provide… think it was also to look at what sort of help is needed and so therefore we would better suited in the future to help.”

NGO: Local-NGO – N/A

Evidence from Documentary Review

Policy:

DoD Directive 5100.46 Foreign Disaster Relief (FDR) (2012): This document was published by the Under Secretary of Defense for Policy and sets forth policy and responsibilities for FDR operations. In circumstances when immediate response is necessary and military forces at or near the scene are available, “the commander should obtain the concurrence of the host nation and U.S. Chief of Mission of the affected country before committing forces.”

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provided to the host nation by other U.S. Departments of Agencies…Require Secretary of State or designee approval.”

Timor-Leste Strategic Development Plan 2011-2030 (2011): This document, created in consultation with all industry sectors and ministries of the government, describes a 20 year plan to develop the nation of Timor-Leste and share these benefits across the nation. The Forward was written by the President of the Republic and clearly states “The Strategic Development Plan will also promote our continued integration with the global community and our social and economic relationships with East Asia in this ‘Asian century.’” This concept is reinforced in the document where it states in this century, “Timor-Leste is well positioned to trade and partner with our neighbours to achieve rapid and unprecedented economic growth .” In the context of health and control of communicable diseases, the plan states, “ We will also adopt a partnership approach that will involve all national and international stakeholders working with our national tuberculosis program .” The plan recognizes the contribution of other partner nations in developing the human resources necessary for an effective health sector by stating, “Despite the extensive medical training program provided by our international partner, Cuba, there is still an overall deficiency of skilled workers in our health sector .”

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Distribution of Themes among Participants

Within Units of Analysis

Across Units of Analysis

310

Means for Testing

Triangulation

Data emerged from different sources to include the key stakeholder interviews and documentary review.

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

Theme emerged between units of analysis: Strategic, operational, and tactical levels.

Reliability/Internal Validity

Theme was mentioned in 25 sources and referenced 63 times.

Theme is considered a plausible element of the theoretical framework.

External Validity

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

311

Appendix EE. Theme: Sharing Leadership

Key Findings Summarized

This theme is a plausible element of the partnership generating impact and is depicted in the theoretical framework (Figure 7). Sharing leadership featured in 15 key stakeholder interviews, within all units of analysis (although at a lower level in PN participants), and across all levels of participation. Content coded as sharing leadership featured most prominently among NGO (38.2%) participant responses. USG and PN were similar at 29.7% and 28.7% with HN coded material making up 3.4% respectively. Among the 33 references coded, operational participants (49.9%) overwhelmingly cited this theme. Strategic (34 %) and tactical level (16.2%) participants made the remaining references during the key stakeholder interviews. The frequency of reporting and prevalence within and across all units of analysis provides reliability and internal/external validity to the theme of sharing leadership. The theme was triangulated during the documentary review where sharing leadership featured in 2 (16.7%) guidance documents.

Evidence from Interviews

Within Units of Analysis

USG: Military – An operational level participant said, “Well, you know, if, if they(referring to the PACOM Commander and Timor-Leste Ambassador) didn’t feel that these missions were important, it wouldn’t happen. This is their mission. I mean, this is happening because they know that this is important.”

USG: Non-Military

A strategic level participant said, “There was definitely a very international flavor to the mission. And the stop in Timor-Leste, the Australians, I think, were probably the most significant of the international partners…the Australians sent two landing vessels and so that actually gave us the capacity to sort of reach, you know, areas and deliver services to areas that we might not otherwise be able to do and it was significant.”

PN: Pacific Region Presence

Both individuals and partners nations shared leadership during the hospital ship missions. Continuity of participation as well as leadership experience played a role in facilitating who and what nations served as leaders in the partnership. A senior level participant described how a participant of another partner nation military was selected as a leader. They stated, “partner nations don’t normally get to be the lead surgeon or the lead gas man or, you know, so she did really, really well, purely because of the longevity she was on that ship…it’s the relationships between the heads of the departments that need to be established and if you’re only on the boat for a one country gig, you don’t get that responsibility… what you bring to the party shows the responsibility that you’ll be

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given.” This participant also described their relationship with the U.S. military hospital ship Mission Commander by saying, “we just got on really well and we had been on the ship for some time and he, like in East Timor he made me do a walk sort of walkie-talkie watch you guys run it and then the second one in East Timor I got to do by myself and then I done a third, there were three in Papua New Guinea by myself, as well.” A tactical level participant described the experience of her nations military assuming a leadership role over U.S. military participants by saying, “Well, it was very different in the third contingent because the Americans, sort of the tables had swapped…So they were the embarked forces, rather than us being the embarked forces.”

PN: Non-Regional Presence – N/A

HN – A strategic level participant said their Ministry of Health, “Provide as much as support that we have and then collaboration, coordination with the local authorities to ensure the successful of the mission.”

NGO: Long-Term Relationship

The long-term NGO participants recognized the evolution of the hospital ship missions in providing leadership positions for both partner nation and NGO participants. A senior level participant said, “in 2010 on the Mercy there was actually some of the British or maybe Australian senior officers that were integrated into the ship’s leadership. So they weren’t just partners augmenting medical staff and so on. They were actually fully integrated into the planning and leadership of the ship. I mean, it may have been an XO that was a British officer or something along that line, it seemed like.” They went on to say, “as we’ve grown together and built more trust, I’ve seen the Navy allow NGOs to, you know, individuals to take OIC roles or site OIC roles, which is a big step I think.”

NGO: Short-Term Relationship – N/A

NGO: Local-NGO – N/A

Evidence from Documentary Review

Guidance:

OPNAV Instruction 5440.75B Administration, Operation, and Logistic Support of T-AH 19 Mercy Class Hospital Ships (2010): This document was published by the Chief of Naval Operations and defines how hospital ships are organizationally structured in both full and reduced operating status as well as command relationships and responsibilities. Within the instruction, clear roles and responsibilities of U.S. Coast Guard, Navy, and DoD organizations and personnel are outlined. Coast Guard ship’s master is in charge of the ship while the internal medical treatment facility (MTF) is placed under the authority of the MTF Commander.

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U.S. DoD Pacific Partnership 2010 Post Deployment Brief (Unclassified): This briefing was presented by the Mission Commander and clearly stated PP10 enabled the U.S. Maritime Strategy with defining aspects related to partnership including: “ Conducted operations with Partner Nation ships and embarked record number of NGO volunteers (411) .” The two listed endstates both focused on partnership. The first being “HN, PN, NGOs seek further participation in PP” and the second “ stronger relations with partner nations .” Among the partner nations there was a “Consistent level of participation; Strong desire for increase responsibility and leadership roles in future PP; and Australia, Japan, and New Zealand already engaged with PP11.”

Distribution of Themes among Participants

Within Units of Analysis

314

Across Units of Analysis

Means for Testing

Triangulation

Data emerged from different sources to include the key stakeholder interviews and documentary review.

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

Theme emerged between units of analysis: Strategic, operational, and tactical levels.

Reliability/Internal Validity

Theme was mentioned in 15 sources and referenced 33 times.

Theme is considered a plausible element of the theoretical framework.

External Validity

Theme emerged within multiple units of analysis: USG, PN, HN, and NGO.

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Appendix FF. Partnership Facilitators and Enablers

Organization Representative Quotes

USG

Facilitator “I think in the areas where there’s a little mistrust and stuff like that, I think the hospital ship is very benign and is much more recognized, the red cross, as a neutral non-threatening thing. A Gray Hull always is, you know, it’s a warship. It brings, you know, the helicopters, the weapons, all those things…countries like Indonesia are much more comfortable with a hospital ship than a Gray Hull.” “Singapore is very interested in participating…Singapore has extremely good healthcare personnel. They’re very well trained, they’re very effective and, and they’re very good and they’re very interested in the regional presence.” “the Timorese, actually, have no hang-ups about the U.S. military, cooperating with U.S. military, hosting U.S. military exercises, unlike perhaps some other countries in the region “And I know that your partnerships are restricted to organizations, governments and organizations, but I think we’re very fortunate here in Timor that the view of the population in general is very favorably disposed to the U.S., and in a sense the ship visits build a partnership with the public, with the people of Timor-Leste. It’s very hard to measure.” Enabler “such a long-term commitment”, civilian-to-civilian such as USAID and the Ministry of Health as well as USAID and the local NGOs, and military-to-civilian such as the U.S. military and Timor-Leste MoH Having “a level of familiarity” and “knowing what to expect when the big white ship pulled into harbor because we’ve done it before and the expectations were kind of standard” were enablers in achieving the partnership goal. In addition to PDSS and Senior Leaders trips, key staff visited ongoing pacific partnership gray hull missions and USNS Comfort missions the year prior to the Mercy deployment. One leader stated, “because I went to Comfort towards the end and they had been beaten up and put away wet, learned these damn lessons, and then I just picked their brain.” A unique enabler identified by one participant was the ship environment. They stated, “so ships, in general, cause camaraderie, natural camaraderie because you’re all eating the same bad food, you’re all there when you’re trying to get on and off the liberty line, I mean, everything is, so you do have that because you’re all in the same place and there’s a lot of people there.” “the Australians, I think, were probably the most significant of the international partners…the Australians sent two landing vessels and so that actually gave us the capacity to sort of reach, you know, areas and deliver services to areas that we might not otherwise be able to do and it was significant.” Leadership was highlighted by one participant when they stated the “Ambassador like to see that here you are one, no USAID, no military, no state.” Another felt the support of their leadership was necessary to be a true partner. They stated, “”I don’t want to compare mission directors and my supervisor, but some supervisors say, “It’s okay. Go to the military and go ahead.”” Partner Nation

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Organization Representative Quotes

Facilitator “I know the Canadians will always have a fairly large role, because your countries just work so closely together, I mean, physically, you’re close anyway.” Partner nation military participants without a regional presence identified the desire to retain a presence in the Pacific Region and the unique training opportunity as facilitators to joining the partnership. One participant stated, “we have a very small military and it’s, and we do not have the, an opportunity such as Pacific Partnership to exercise our medical folks using a variety of different platforms such as a Navy ship, you know, landing crafts, helicopters. So as far, for us, it’s a great training opportunity.” Enabler “Every day they would say this is how many people we’ve seen today…so that was actually really good, keeping everyone up to date…everybody really enjoyed that and I think that really helped cement peoples’ relationships and make people think, feel they were a part of something.” Another participant cited the integration of specialists both on ship and on shore during the mission assisted in galvanizing the partnership at the individual level that may transcend to the organizational level. They stated, “Like I still worked with my (partner nation deleted) dentists a little bit but like, yeah, I know the Canadian dental assistant worked with him. When we’re ashore we worked with the like Indonesian dentists. I worked with American dentists. So, yeah, it was definitely mixed up, again, it was like say, you know, the hierarchy in dental, the chiefs or whatever, like what I saying that they put us on a roster to rotate us, on the ship, ashore…they mixed that up for us, so, which was good, yeah because otherwise, you probably would just stick with your (partner nation deleted) dentist the whole time, but it was good. We were made to integrate with everyone and, yeah, I loved it.” “I was very fortunate in the sense that I had the continuity and I had the links already in the various headquarters. So I was able to get a lot of the information a lot sooner than other partner nations, I would imagine and to always sort of be one step ahead.” Host Nation

Facilitator N/A

Enabler “the host nation has a strong commitment, like I can see the government at that time give a strong priority and very supportive of the mission. So at the time, me, as a, in my position, I also give a strong support, commitment and then if the ministries have strong support and then the government and then the districts will give strong support. So it’s good but probably if the commitment is not there, it’ll be difficult. So it is the political commitment and then support.” Another host nation participant stated “Before the ship arrive we work with (name deleted) from USAID…we got many support from the USAID and we have also very good coordination.” NGO

Facilitator The long-term relationship NGO described historical relationships beyond hospital ship missions between their CEO and senior DoD officials and the permissive hospital ship platform as facilitators to joining the partnership. The short-term relationship NGO described the role of communication with other NGOs who have participated on previous hospital ship missions as a facilitator to joining the partnership.

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Organization Representative Quotes

Enabler One participant described his former military status as “a help because the other NGOs kind of looked to us. I mean, I think they understood we knew the ropes a little better.” Another participant highlighted the shared leadership among military partners by stating “in 2010 on the Mercy that there was actually some of the British or maybe Australian senior officers that were integrated into the ship’s leadership. So they weren’t just partners, you know, augmenting medical staff and so on. They were actually fully integrated into the planning and leadership of the ship.” Frequency of deployment was mentioned as an enabler by one participant when they said, “I don’t think there would, the partnership would, there would be anything there, but the fact that these are sustained programs, I think allows that partnership to maintain and sustain.” “So maybe us being with Australia made an impact of being more able to trust us.” Without employer support, finding volunteers to support the hospital ship partnership would be more challenging. One participant stated, “My employers were behind me 100% and kept my job open for me. I was there for the four full months and then I took another month off and went to Australia afterwards and they were very supportive, yeah, the whole way through.” In terms of continuity of personnel, one participant stated “from PP10 to PP12 the Pacific Fleet planners were the same personnel, which tremendously added to the feeling of partnership and the execution, I think, of the planning of the mission.” A unique enabler that was enacted during the 2012 mission was ““a Civil Military Coordinating Council aboard ship. That’s the first time that’s been done and that was at the CP13 planning meeting, all the NGOs have come forward and said, “Boy, that was a good thing,” because we were more involved in the process and not just being told what to do, so to speak.”” “the Ministry of Health considered this implementing partner as very important partner because they make bridge, they can bridge between additional resource and the government.” Another stated, “Now I think it was very positive that the initial meetings were held quite some time before the ship’s planned arrival date and so that did show good kind of preparation.”

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Appendix GG. Partnership Barriers and Constraints

Organization Representative Quotes

USG

Barrier “Some NGOs don’t go near the U.S. military and just the fact we’re on a hospital ship, they don’t really embrace our missions and then, you know, like we’re never going to have Doctors without Borders onboard the USNS Mercy.” Internal Constraint “I don’t think we should rotate all of these staff, you know, every month because it’s such a pain in the butt to reorient to completely train and orient a bunch of new nurses to the ward and how we do things and, you know, some of these reservists, boy, they haven’t necessarily practiced actual bedside nursing in twenty years, you know. What are they doing out here?” “I’ve done the ’08 mission and ’10 mission and, you know, it was just painful to watch a new group of people come in ’12 who had never been involved in the mission before and they’re kind of going through the same thing that we had learned. So if you took some people with some experience, it doesn’t need to take a lot, for a country like Timor, if you had just one or two medical people who had been on previous missions, if they went in there a few months early and worked with the embassy and with the host nation team, you can craft a much more efficient and effective mission and you could also build, you can focus on a few key medical programs that we’re interested in developing over the next five, ten years and they can really leverage that and make the mission much more effective.” “what actually hurts the partnership the most is the fact that next time an American ship goes there and does med-caps, it’s going to be a whole new cast, cast of characters and that actually does kind of hurt us.” “going into a country for five to seven days does not get you anywhere.” Another participant stated, “it was such a short time, it’s hard to know if there’s any lasting, you know, lasting impact.” “in medical education it takes years of training and we go in and we have this idea that in just a two week visit we’re going to build capacity. That’s really a hard thing to demonstrate…to build healthcare capacity, you have to go back on a regular basis.” “I think they all will acknowledge that they’re, you know, they want to build capacity and stuff like that but ultimately it comes down, because they’re, they’re involved such a short time with the mission, they look for short-term things, how many people were trained, how many patients were treated, and stuff like that.” “I think a targeted time anywhere between probably, you know, two and four weeks is good. Beyond that you tend to have too much of an impact and too much of a draw away from the practice of the medical practitioners already in the country, for instance. We have to always be cautious of that. You don’t want to take away, you know, all the surgical cases from the only surgeon in town.” “We certainly bring NGOs but a lot of them tend to be a little more like medical tourism, you know. They go. They want to see things. What we really have to do to do a better job in Timor is align with the in-country NGOs. Probably all the, all of the countries that we visit, we would do better if we aligned better with the host nation NGOs, the NGOs that are there already. So to bring a U.S. NGO that doesn’t have a footprint there already really negates some of the benefits.” “I think if we’d known that NGOs that were in-country, we could’ve worked better and gotten a lot more of bang for our buck by getting better alignment with the host nation NGOs, especially in Timor.”

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“the Pacific Partnership would be more effective if all our embassy, our in-country military groups had more of a plan, but they don’t, you know, they don’t have medical assets assigned to them. They don’t have medical planners long-term, so they really don’t have a plan.” “The other problem with the Mercy is you don’t necessarily bring, you know, the PDSS, the country tells you what they’ll want. You try to shape your personnel to that but ultimately you bring, you bring who is sent to you. So partner nations send a very random assortment of doctors… It’s people who have earned favor and who are owed a trip, you know…The NGOs from the U.S. send a very random assortment, you know. A lot of your nurses and your doctors from the NGOs are people at the end of their careers. Some of them have even stopped practicing a couple years before and yet they’re, you know, for them, it’s kind of medical tourism. I think that’s a big, big issue we have with the NGOs is, is they have people who have time to go on these missions so they’re all 60, 65 years old, some of them haven’t practiced in a couple of years.” “France sent, it was atrocious, you know, they sent two people, one never even sent her credentials. She showed up. It was really kind of medical tourism, and then the other one from France came and said his mother was sick and had to leave like two days later.” “I basically took, you know, three or four courses, some of these two-week or one-week courses to get all of this crap in my head.” “I sort of felt at the end of this mission we pretty much knew kind of what we needed to track, however, we didn’t have any way of knowing how to track the, the public health, you know, the capacity building.” ““One of the issues across DOD is, you know, what measures of effectiveness have we put in place to see how successful our engagements have, have been. From the hospital ship perspective, obviously, it’s not the right vehicle to do a long-term assessment since we’re there for two weeks and we’re gone. We become dependent to a degree on the, the State Department and the Embassy staff to come up with, “Well, you know, did we achieve what we wanted to achieve in the long run?”” “I think maybe we were, the U.S. was a bit ambitious. I mean, we, we had a lot of stuff planned. We had to, we probably could’ve toned it down but we did get a lot of stuff accomplished.” “USAID groups vary. Sometimes the leadership, even though they don’t, they’re very cordial with you and stuff, but sometimes clearly they’re just not that interested, I think. Sometimes the, you know, in my opinion, some USAID leadership people come out of the Peace Corps and they’re very, very anti-military. I think in Cambodia, they actually were kind of anti-military but they also were very progressive and they were very, I think they recognized the Pacific Partnership missions for what they were. They were opportunities to build huge amounts of goodwill for their, their programs that they had been developing with the host nations. And I think if USAID in, in Timor-Leste and also AUSAID, if they would recognize that, they could get a lot more leverage for their programs by using the Pacific Partnership missions to advance their, their programs.” “we depend upon USAID to help identify those partner nations or those partner NGOs ashore, and I think that perhaps our collaboration with USAID was not as strong as we had hoped.” ““There’s still some resistance, I felt that USAID and different individuals because there are some people are not interested in dealing with the military. They don’t feel that the military has a role in this type of mission. I always try to sell it to them as, “Hey, we’re one tool in the tool bag and you need to learn how to use us because we can further the mission that you’re trying to achieve. You, we can further the long-term diplomatic goals of the country through these missions.”” “the problem is for most of the people who participated in the Pacific Partnership ’10 they never ever, you know, would probably are going to return to Timor. So in terms of individuals, the, those aren’t real relationships. There was just, you know, the relationship lasted as long as the mission…. that sustained approach is probably necessary to have lasting impact.”

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“I think the military is great. They really want to do the right thing but this in-and-out doesn’t really lead to anything… It has to be longer, it has to be something that’s started and nurtured and developed and seen through. A one-off shot or once every year in-and- out is not going to, in my opinion, leave you with a strong partnership.” Another participant stated, “the sustainability of those partnerships and the sustainability of the medical, you know, services and treatment provided is certainly inhibited by the fact that the mission lasts, you know, only a week.” “So it also leaves me in a difficult situation because once I’ve gone out to those communities and started children on immunizations, I need to get back within the next three months. That’s going to be challenging.” “It’s such a short period of time that it cannot serve as a partnership because it’s not ongoing but what it does do is, I think, de- legitimize the service that the Ministry of Health is trying to do…. countries that are in a sort of transitional state, you know, moving forward with a growing economy need to have more sustained efforts over a longer period of time with a sort of more [inaudible] rather than a short injection of a mass load of resources in, you know over a ten-day period.” “to really maximize that it could really be maximized by more daily partnership…Often times USAID or, you know, Portugal or Australia, we come in with such a prescribed agenda and to the counterparts, they want it, obviously, because they understand it’s the basic equation that, “Well, it’s probably going to be better than what we have now, so I’m going to approve it,” but they don’t own it and they don’t, because they weren’t part of so much of the legwork.” “the NGOs that were on the vessel were not, are not ones that we worked with in Timor traditionally. I think they pretty much only came, you know, with the mission. In terms of the NGOs on the ground, yes, I mean, obviously, we work very closely with them. I wouldn’t say that the mission contributed a whole lot to developing those partnerships.” “given the resources devoted to sustaining a mission like Pacific Partnership, were, you know, were the results commensurate with the resources invested? That’s, honestly, I couldn’t definitively answer. I mean, I’d need a lot more information about kind of, you know, how much this costs, et cetera.” “I don’t think that there was, my sense that it was something that people had been tasked to do. There wasn’t a sense of necessarily thinking about any sort of sustainable partnership over the time. It was purely to serve a purpose, to get the job done, and I think given that it was the sort of in-out, once the job’s done, people walk away and then the people that they were sort of trying to serve, which is the community and through the Ministry of Health, they don’t receive any feedback after the task is done. So from my sense, it serves more the purpose of the people who are coming in and not necessarily the objective that it’s supposed to achieve in sustaining a sort of a partnership that the Ministry feels that they can rely on in the future.” “from the USAID perspective, our mission is to work hand in hand with those three groups you mentioned and develop a relation, a trusting relationship over a period of time. The goal of the boat, as far as I understand, is to come in, do a lot of high impact quick things, give lip service to developing partnerships and then leave.” “Now if you talk to somebody from USAID, particularly the people who worked on health, I don’t think they see the Mercy as, you know, directly contributing to their, their health efforts. And probably there’s a little bit of resentment that the DOD has the kind of resources to throw at a, sort of splashy, one-week, you know, type mission like this.” “I think the fact that it’s all one activity of every year and it’s not then continued. So it’s not something that people can feel prepared for. It’s something that’s, they have, everybody has to stop what they’re doing in order to accommodate this particular activity…So it’s something that sort of stifles them…and everybody else has to adjust to respond or accommodate the military.” “I don’t know that necessarily that the USAID particularly has the time or the attention to do something with the military…So if

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they’re not involved it, it could potentially, you know, ruin relationships in the future because I think there’s always a distinction between USAID and the U.S. government and other military.” “they sort of have their jobs done slightly faster than the Ministry, you know. We’re working in a pace here and they’re working in a different pace than us. So it’s much more of a humanitarian model and we’re not operating in a humanitarian program because we’re not humanitarians we’re working development.” “things could really move fast, much faster than our experiences have been within the Timorese health sector and so what we imagine is happening is that the exercise is taking more ownership of the partnership than perhaps it should… at the end of the day, we’re still trying to, for lack of a better phrase, pound kind of square pegs in round holes.” “Phew, now we can go back to our normal pace, good grief. Those Americans are going to kill us.” “they want everything to be planned and delivered with a timeline that is almost like a, you know, people sending a ship to the moon.” External Constraint the MoH was “very eager” with “very good intentions, but poor organization, poor execution.” “the biggest challenge was the follow-through by the Timorese government…that was definitely the most difficult and I don’t know, there’s really nothing that we could do to change that, I don’t think. I think it’s just the innate, as their government matures and becomes more professional that’ll come with time.” “news does not travel well…we’re limited by the fact that news does not travel through Timor-Leste.” “it was quite a challenge in Timor to get the host government to really see themselves as equal partners in this mission, and that was generally true, yeah, it was true with both Pacific Partnerships. But that’s, I think, more due, not due to a lack of willingness on their part but more to general lack of capacity on their part, you know. They just don’t have that many key people with sort of that, the vision and with the English language expertise and the technical expertise to be able to sort of, and the time to be able to engage as full-time partners in an effort like that…It certainly didn’t hurt, you know, may have improved it somewhat, but did not, was not a, you know, dramatic substantive difference after the fact.” “we tried to work very closely with Minister (name removed) and his staff at the Ministry of Health. We had to work that hard because the capacity of not only that ministry but in general the Timorese government was pretty challenged just by the limited resources that they had available.” “So if the Timorese don’t have anything approaching the, the services that the Mercy or the capability, they have nothing approaching the level of or even the nature of the capabilities that are provided by the Mercy and so there’s a limit to the interaction that can take place between the two.” “my suggestion was that we temporarily bring in somebody else from another mission to actually deal with the military so there’s some sort of liaison between USAID, who’s familiar with military speak and can actually help brief USAID teams and also take the burden off the team that is on the ground because they get distracted. They have to go out. They have to be participating in the meetings. They often have to organize the meetings and it puts us back, you know, with a contract because of the time it would take off of [inaudible] particular time. So we had a delay in issuing a really important contract, which actually did impact our relationship with the Ministry of Health.” Partner Nation

Barrier N/A

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Internal Constraint “the (partner nation name deleted) doesn’t use NGOs to, to anywhere near the way that the U.S. does at all. It just doesn’t happen. I mean the only civilian people that we see are contractors. There’s really, I don’t deal with NGOs in the Navy at all. They’re just not there.” “Civilians were a strange bunch. Some of them were incredibly naïve and just didn’t get it and therefore their interactions were pretty reserved or when you came across them, interaction was mainly complaining but, you know, the military just got on with each other and, you know, I’d like to say I kept in touch with military. I’ve not kept in touch with any of the NGOs or, you know, any of the other civilian agencies.” “I’m used to our health system where nobody talks to each other” and “even though you may have, you know, these people from all these different countries doing exactly the same job, everybody in all the different countries do it slightly different.” “a lot of the, the Americans…were like, you know, “Oh, we finished work at, you know, 4:30”…so I thought that was a bit funny because I was like, “Oh, my God, we’re all stuck on this ship, like I don’t mind seeing patients,” you know, ‘til, you know, 8:00 at night or whatever. So but I got permission of my dentist and, yeah, I was allowed to see patients past closing time, so, yeah, I was happy with that, you know. I felt like I was still giving it my best, with the time constraints that we had… so I definitely think it was because we were fresh and we were only on there for a short period of time. So we weren’t as worn out, so to speak.” “I believe we were shipped as just simply participants and our job was to not have any impact on the execution of the mission, just simply ride the mission out and provide a, you know, a capability that the U.S. Navy or other DOD organization couldn’t do it. We did not have any impact on any part of the execution of the mission.” ““one of the difficulties that I experienced with planning from year-to-year was the loss of that continuity. There’d be a staff, a new Commander, and of course, you know, he would bring his staff and they would have a different way of doing it. So every mission I viewed it as, “Okay, we’re going to start over again and, and go through the learning experiences, the growing pains of trying to get familiar with new staffs, particularly at the tactical level, at the at the operational level… but at the higher levels, the strategic level there was continuity.”” “we understand that this is the U.S.’s show. We understand that but we were not given, you know, I won’t say equal treatment but when we approached the American Public Affairs people to try to, you know, get an article out on (country name deleted) interests or what (country name deleted) are doing it was difficult. It was difficult. It was much better now than it was in 2008 and definitely 2010.” “Maybe if there was a few more people from each country, like I know we were spread pretty thin. So like I say, I knew there was Australians there but I didn’t really see them so much. Like definitely, I mean, there was U.S. Navy everywhere, so we were with them all the time but the other countries, there was very few.” “The only NGOs that participate in Pacific Partnership come from the U.S., so our relationship with the NGOs, we don’t have one. And the only thing we do is we only provide mil-to-mil support. There was some talk of trying to get some Canadian NGO involvement into these organizations but we have such a, as a military, we don’t coordinate very well with our NGO partners. It’s not something we do as a normal course of business.” “I know that we have actively tried to engage our other governmental organizations to try to get more collaboration but every day it seems, you know, every time there’s, whether it’s a domestic emergency within Canada or whether it’s an international event, such as Haiti, it always seems that every day is a Monday and that we’re trying to rebuild these linkages with these organizations.”

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External Constraint N/A

Host Nation

Barrier “It’s a young nation, very limited to resources… the Ministry of Health in Timor-Leste we have limitation of capacity, as well, limitation of resource, as well, even we have resource but also how we can look at the resource, organize the resource and also controlling the resource.” “in Timor-Leste everything that people do is like we want now, we think about short, medium term. We don’t think long term, and I think the government is trying to work on that to think more in a longer term while also filling the gaps to get there.” “in 2010 I know that the challenge is the district is not ready.” A host nation participant claimed the hospital ship participants “have a big group so they can move quickly but for us, like it’s not easy for us to follow.” “But I think one day maybe, I know that one day we have the experience.” Internal Constraint “if there is a criticism, I would say that perhaps communications afterwards with the mission. I’m not sure whether the doctors that were involved whether they communicate, whether they exchange knowledge, they exchange experience, whether when they experienced challenges at the hospital, whether they contact some of the doctors that were here or, or even those who stayed to work in the NGOs who’ve collaborated during that period, whether they kept in touch at the same level for exchange of knowledge and experience.” “that is very important but after 2010 ‘til now we don’t know the goal, if the program is still running or not, but, you know, in my point of view is very important for the new country, for the developing country.” “I can honestly say that after the mission leave and then we don’t have any communication with the Navy. That is one of, how you call it, one of the problem, challenge. I think with the next we need to get a system, when the Navies are here we have a good coordination, good communication, good interaction but after they leave, and then we don’t know, maybe after two years they’re coming back or not, we don’t know but it’s definitely we need create a communication link.” “I think that stop, but because the USAID office is here, so it’s easy for us to contact, but not for the Mercy.” “The difficulties or the challenges that we face at the moment is related to the diversity of the languages. Some mission there’s some from Canada, some from Asian people, some from American, as well, and then Australia, the diverse type of language and then diverse kind of English and then sometimes it make complication to the community.” “So the important is the immediate evaluation after implementing these activities is very important, as well. It’s good to have independence association or independence groups or independence body or independent people to make investigation but also how we can handle it ourselves, our program, and then we know that this is a success and this is not success how we can blend and also how we can make it work. If not success, we can make another strategy to be more successful in the future.” External Constraint N/A

NGO

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Barrier Although not related to Timor-Leste, an example provided from Vietnam where the U.S. “had to negotiate with the Vietnamese. I mean, obviously, they invited us to come there. It wasn’t like we were invading them but still there was some sensitive issues and they didn’t want helicopters to come ashore, you know, because of their experience in the war. They nobody wore uniforms ashore. Everybody wears civilian clothes, you know, too, and so there, there was a sensitive issue.” ““in my talking with university faculty and medical school faculty and medical students, you know, I think they’re a little wary, they’re a little, “Ew, would I want to go on a Naval vessel, and would I want to be around all those people in uniforms and all those rules and regulations? That’s not what I want to do.”” So I think, if anything, there’s a little bit of reluctance.” ““NGOs and military there’s always that kind of cultural clash to some degree… health NGOs in particular really focus on long-term sustainable public health projects and these DOD missions, again, outside of the training and the diplomacy and those sorts of things, in terms of the actual care given some argue are even, you know, somewhat dangerous or irresponsible and you can make your own mind up or, or others do, as well. But a lot of NGOs look at the type of the actual mission work and say, “This isn’t really good public health. This isn’t something that our organization wants to align with.” So that’s kind of the base starting point.”” Internal Constraint “there is some competition between the NGOs, you know, and I’ve known that for a long time. That’s what came out of the tsunami, that somehow leads to chaos actually and that’s one of the things that we worked to try and overcome.” “the DOD or the U.S. government in general has got that kind of, you know, can’t show favoritism and so whether you put a box of Band-Aids on or you send thirty volunteers onboard, you’re getting the same level of publicity and credit. And that can be a bit frustrating but, you know, everybody, again, understands it and nor do we really want every other NGO to participate because that would take away slots that we would like to fill. So, I don’t think that spectrum is a big deal outside of the fact that the recognition sometimes gets a little frustrating when that media coverage is such a big part of what we do.” “NGOs, in general, are kind of in a competitive environment and so, I think outside of these missions, there’s no additional activity.” “our interface with USAID is virtually nil. They may have a rep onboard. They may have a rep at a planning conference but I would guess most of the USAID involvement really appears to be, from my perspective anyways, appears to take place early on in the planning, maybe in the pre-deployment site surveys and at the host nation kind of interface level but for the actual mission execution, I mean, it, we rarely see them and it hasn’t done anything for really for our interaction with AID or, you know, having DOD missions somehow make the relationship better and build confidence in (NGO name deleted) activities, in our global health programs. I mean there’s been no connection there at all.” “I rarely see the local NGOs and I don’t think the U.S. NGOs onboard the ship really have much, if anything, to do with the local NGOs that are in-country…And so, you know, a lot of times, there’s just a disconnect there.” “DOD likes to present the NGO participation because they’ve got this kind of follow on tail to the head that comes in and it does brief well and I think in theory it’s fine. It’s just finding a way to make the work sustainable and allow the NGOs that are participating, provide them with an opportunity to create a long-term program in-country.” “you’re switching countries and even within a same country, if you go to a different support city the next year, you’re not at that level of sustainability… I don’t know how the partnership really goes but I couldn’t imagine it’d be too good.” “the cast of characters changes so much.” “When those partnerships end, we basically wind it up and wait for the next year of planning cycle to do it all over again with a new set of staff, a new, you know, a newly rotated in staff with different ideas. It’s like Groundhog Day starting all over again with a new staff of people…there’s so much rotation of staffs, differences of opinion. There’s no continuity or follow through.”

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“I can’t think of a single country where the relationship with USAID has maturely affected any future follow on missions although, we would’ve liked it to and I often hear and feel and experience that these annual military sponsored missions are more an annoyance or an interruption of, you know, USAID planned operations than anything else and that they’re basically endured rather than supported. I can’t remember a single one that’s been tied with an ongoing USAID program. Basically, USAID blesses them and says, “Go ahead,” or gives a recommendation of where or what we ought to do in addition with the indigenous Ministry of Health or health authorities say but I can’t think of a single instance where USAID has followed up or followed through or continued or enhanced any of these ship missions.” “Why they, why am I here? I’m wasting my time doing this or that. I’m not helping anybody,” you’d have to tell them, number one that, “No, you’re not healing people necessarily, you know, 9 times of 10 what you’re seeing is reasonably healthy people who have a headache or a stomachache and you’re giving them [inaudible]. You give them vitamins and they leave and they’re happy but it’s not unlike your own office, I mean, a good number of people you see aren’t in a life and death situation. They’ve got a headache. You’re not sure what they have but you’re showing that you care and you’re giving them hope and then in the case of this mission, you’re showing that our country cares.” “I think somewhat farther down the line is support the beneficiaries, which, you know, tends to be a little bit lower down the chain, and for volunteers that don’t understand the concepts of the medical diplomacy and the relationship building and that sort of thing, when they’re there just to help sometimes you got to really manage that expectation.” “there were no missions or objectives to improve the health of the indigenous population as provided by any sort of measurement or evaluation standard. I mean, it was to provide primary healthcare but frankly it was essentially to see as many patients and document as many patients as you could. That was and still appears to be the measure of success, is the number of patients seen, number of procedures performed, number of surgeries performed, number of pharmaceuticals issued, teeth pulled.” “what measure of effectiveness or evaluation has DOD used to, you know, figure out are these worthwhile? Are they worth the time and money spent and how could they be improved? And I think if you sit down with any public health person there are many ways it could be improved and sustained over the long run with a true partnership. The Navy being the short term, the NGO, some of the NGO being the long term. I don’t think any of this has been developed.” “I think, giving the civilian partner equal partnerships. Say when we go to a planning conference the Navy’s running everything. The Navy, with the country team, State Department, USAID, they decide where they’re going to go, how long they’re going to stay, what they’re going to do. The civilian NGO partners, quote partners, have no say in any of those mission parameters.” “I think you can evaluate the partnerships by terms of the Memorandums of Understanding that every civilian partner has to sign with the DOD sponsor, in this case, the Navy. The MOUs, if anything, have gotten tighter, more constrictive than they were in 2005 when we started in terms of what the Navy will or will not do and in terms of what they expect the NGOs to do or not to do… all I can say is the more we provided, the less we got. It was confounding… sometimes when we feel like participants, the partnership is there but it’s also a bit more one-sided than what I would consider more of an equal sharing of resources.” “So yes, we are partners but we don’t really have, it’s not an even partnership. It’s, you know, we participate. We get the requirements. We go where we’re told and so on, not a lot of mutual interchange there in terms of country site selection and all of those things…sometimes the reality is a little different than I think what the slides present.” “as far as like using my nursing skills, I didn’t. I don’t think there was maybe more than two or three times that I actually distributed medication or started an IV or, or anything on a nursing skill basis, things that I do on an ordinary daily basis of my own work.”

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“I really don’t think that it was fully understood how incredibly difficult it was, you know, for us to interact with the Navy, with some of their expectations and having to be accountable every minute to them…I think basically the NGOs need to have a little bit of independent operation away from the Navy protocol. In other words, they were responsible for us, yes, definitely, but we are all adults and we know very well how to take care of ourselves.” “they went expecting to be treated and respected by Navy nursing personnel and I think a lot of us, and I don’t mean this in a derogatory way, but not respected at all as far as nurses.” “if you could spend longer time there, you’d obviously build better relationships…So time, if you had more time, obviously those partnerships would be built better or if you had, I don’t know, a group that went back afterwards to see how they were getting on, what we’ve learned from each other and then bringing it to the table, making suggestions for next time. I don’t know if that happens. It might already happen.” “Typically, in these projects there’s new folks every year…they’re reinventing the wheel every year. All of us in the NGOs are pretty much the same people every year, so there’s a bit of a frustration in dealing with a whole new crew of folks who frankly don’t often know how to pull it off.” “every year we personally feel like we kind of and our team feels like they have to reprove ourselves, that there doesn’t seem to be much institutional memory when I go to the planning meetings, at least for the first one, you know, I’m meeting a whole bunch of new people who have probably heard of (NGO name deleted) but are not really familiar with what we can bring to the party.” “it would be nice to have a kind of the evaluation meeting with the Ministry and stakeholders and ask for the feedback because if it is partnership then maybe both, Ministry could do better or the U.S. Navy, they could do better. So it would be nice at the end of the mission, they could find out the gap, strength, weakness, and what can be done for further. So I haven’t seen this happening so that, in my opinion, if they could do that, that would be nice.” “So when they left, they could have like follow up or review some kind of the activities and it was not clear when they would come back and how they would keep in touch with the Ministry of Health and the other people and other organizations supported. So U.S. Embassy, though, I appreciate it and also the team leader of U.S. Navy, they appreciate it. But still the gap is there, the follow up plan. Nobody could say that, what will happen after the mission.” “it would be nice to have a kind of the evaluation meeting with the Ministry and stakeholders and ask for the feedback because if it is partnership then maybe both, Ministry could do better or the U.S. Navy, they could do better. So it would be nice at the end of the mission, they could find out the gap, strength, weakness, and what can be done for further. So I haven’t seen this happening so that, in my opinion, if they could do that, that would be nice.” “So when they left, they could have like follow up or review some kind of the activities and it was not clear when they would come back and how they would keep in touch with the Ministry of Health and the other people and other organizations supported. So U.S. Embassy, though, I appreciate it and also the team leader of U.S. Navy, they appreciate it. But still the gap is there, the follow up plan. Nobody could say that, what will happen after the mission.” “because those people living in very remote villages, it’s not easy to deliver the message to the very people that live in very remote villages.” He went on to state, “also lack of communication at the Ministry of Health side, how to coordinate with Community Health Centers in the very remote villages in Timor.” “in 2008 was the first time that Operation Smile was part of the ship. And that really caused some problems because they were not aware that our teams had been doing ten years every single cleft in this country, since 2000, ’99 actually and they weren’t aware of it

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and they weren’t aware that we kept a register…but the Ministry who didn’t tell them, of course, got patients from [inaudible] bypassing the place where our team was a few weeks before, coming here to the ship and so that was sort of, you know, working against each other unknowingly.” “to me it seems it’s about PR and not all about health…It’s a PR exercise.” ““if you were to want to help me…then the best thing to do is to go to me and say, “How can I help you? What do you need help with?” Right? Rather than coming to me and say, “I’ve got a new washing machine, which is very useful for you, do you want it?” And I’m inclined to say, “Yes,” am I not?”” “I suppose I would describe my NGO’s activities to be very distinct with the Mercy ship from our activities in Timor. And that’s a shame, yeah, because really they should be part of, part of the same mission.” Another internal constraint previously mentioned includes resentment among partners. “However unsustainable that system is and it’s not designed to be sustainable, so, you know, if the Mercy ship is going to kind of continue missions like that, it would be foolish to not try and maximize that. So if USAID and the Embassy believe it’s important then they should put the proper in-country resources behind making it a successful mission. The ship coming in of itself is not enough, in a sense, that’s the easy part, you know. It’s already equipped. It’s already got all the specialists but to make that successful is all the hard work beforehand and so for me, some of the fault would lie, within USAID not doing enough and that’s not doing enough coordination but also specifically with the Ministry, you know, and I think if the Ministry don’t see it as important for Timor, well, then that needs to have some reflection.” External Constraint “I think, in order to have a true partnership you would need equal standards. Obviously these countries don’t have the medical provision I assume that the U.S. has…So I think there wasn’t a huge amount of medical people there to share information with. I know they came onboard, so that was good.” “I think it’s difficult to share, to have a true partnership when there’s very different standards from the beginning. I don’t know. I think because we obviously have a much higher standard of care…it’s very difficult if they haven’t got the equipment that we have. So I think their hospitals aren’t nearly as equipped, as well equipped as ours and they don’t have the medical provisions that we have. So it’s difficult to have a very true partnership, I think.” “if you look into the capabilities of the health system, Timor-Leste still in term of human resource and in terms of the logistics still insufficient.” “I still don’t see the Ministry of Health to come up with some strategy to continue with the collaboration among the partners in the country. So I guess, this question you can ask the Ministry of Health to answer what they think about this because they are the one that should be leading this and they should come up with some strategy to continue without the presence of Mercy ship.” “We also tread a careful line and we would want to be supporting the Ministry of Health in its partnership with the Mercy ship, but if the Ministry of Health doesn’t have a relationship with the Mercy ship then that’s, that’s quite hard to do.” “I don’t know why there was nobody from the Ministry of Health. I have heard in the past that the Ministry didn’t necessarily want to be engaged. However, just knowing some of the personalities involved, I think how different people being, trying to engage the Ministry, I think it could’ve been much more successful.” “those people living in very remote villages, it’s not easy to deliver the message to the very people that live in very remote villages.” “also lack of communication at the Ministry of Health side, how to coordinate with Community Health Centers in the very remote villages in Timor.”

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