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