Military Review English Edition May-June 2014 | Page 59

M E D I C A L O P E R AT I O N S
Insurgents are drawn to rural communities that
are underserved by the host-nation health sector.2
Because COIN is primarily a civil-military endeavor,
properly leveraged expeditionary medical assets can
be force multipliers in the effort to improve governance and marginalize the activities of insurgents.
This article examines the theory and practice of
COIN operations conducted by a forward-deployed
special operations surgical element in Uruzgan Province, Afghanistan, in 2012. The Tarin Kowt Forward
Surgical Element (TK FSE) was uniquely integrated
into the regional special operations task force (SOTF)
COIN mission and contributed to the expansion of
medical care in Uruzgan and beyond. The experience
of TK FSE in Uruzgan should serve as a model for
future special operations and conventional military
medical unit participation in COIN missions.

Assessments of needs and health sector progress
should be performed continually during any health
operations in COIN. Engagements and programs
should be flexibly designed and executed to allow
for responses to fluctuations in local sociopolitical
circumstances and changes in the security situation.
Measurement of outcomes should be planned for
from the beginning of any health program in a COIN
mission. The output of foreign military activities in
the indigenous health sector is easy to measure, in
terms of the volume of patients seen and treated. The
outcome of a COIN health program is reflected in
the ability of the host nation’s health sector to care
for the population; the key data to capture and use to
plan further engagements will measure this outcome.

General Principles

Uruzgan Province, located in southeastern
Afghanistan, has just over 300,000 inhabitants and
is one of the poorest, most rural areas in the country.
The province has one hospital, located in the capital
of Tarin Kowt (TK Hospital). This facility provides
referral-level care for the residents of Uruzgan and
parts of the adjacent provinces of Day Kundi and
Zabul. TK FSE was a small U.S. special operations
medical facility, established in 2010 and located on
a base just outside the city of Tarin Kowt. The FSE’s
primary mission was to provide combat casualty and
acute primary care for coalition special operators and
Afghan partner forces from southeastern Afghanistan. The FSE was adopted an additional mission to
leverage its assets in support of the broader SOTF
COIN mission. The goal of the engagements arising
from this leverage was to increase Afghan regional
healthcare capacity and decrease reliance on coalition medical assets, especially for trauma and acute
surgical care. The expected strategic outcome of
this mission was further legitimacy for the Afghan
government, reinforcing it as a provider of health
resources for its people.

The goal in COIN is to promote the legitimate
host-nation government as a source of stability and
order in the lives of the indigenous population.3 To
this end, medical operations should focus on increasing the capacity of the host-nation health sector and
promoting the host-nation government’s role in the
people’s health. Military medical programs that
provide direct care to local nationals can be useful in
the initial stages of a COIN engagement to gain the
trust of the populace and accustom them to foreign
military involvement in their health care. However,
direct medical care should be avoided in the long
term because it eventually leads to undesirable reliance on foreign medical care and marginalization of
the country’s health sector.4
In contrast to direct care, capacity building can
be achieved in two ways: first, through the focused
delivery of sustainable direct health and reconstruction aid, and second, by leveraging medical skills
and knowledge through training programs and partnerships with the country’s health system. Both of
these require intensive engagement and relationship
building with key health sector leaders. These relationships should form the basis of all COIN health
engagements. Specifically, military and host-nation
leaders should jointly conduct real-world needs
assessments to develop reasonable goals for COIN
health programs. Local leaders should maximize the
use of host-nation personnel, facilities, and materials
in any planned health sector interventions.
MILITARY REVIEW

May-June 2014

TK FSE and Uruzgan Provincial
Healthcare

Afghan Medical Training
Partnership and Validation

TK FSE initiated the Afghan Medical Training
Partnership and Validation (AMTPV) program in
2010, which was TK FSE’s primary COIN medical
engagement. The program was a response to an
assessment by SOTF medical personnel—through
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