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miércoles, 19 de julio de 2017

NATO ROLE Support "Role" or "Echelon. Military Hospitals

NATO Operation Medical Conference 

Hospital in Herat. Afganistan 

Dr. Ramon Reyes, MD

Medical Support

Role Support

1610. The term "Role" or "Echelon" is used to describe the stratification of the four tiers in which medical support is organised, on a progressive basis, to conduct treatment, evacuation, resupply, and functions essential to the maintenance of the health of the force. "Echelon" or "Role" is defined on the basis of capabilities and resources, and is not specific to particular medical unit types. The term "role" is used by land or air forces, while "echelon" is primarily a maritime term. While closely related, they are not exactly interchangeable. The treatment capability of each role/echelon is intrinsic at the higher level, e.g. a role 3 facility will have the ability to carry out role 2 functions. Each level of support has the responsibility to resupply and otherwise support the levels below them. There is no requirement that a patient must necessarily pass through each echelon of care in progression during treatment and evacuation.
1611. Role/Echelon 1 medical support is that which is integral or allocated to a small unit, and will include the capabilities for providing first aid, immediate lifesaving measures, and triage. Additionally, it will contribute to the health and well-being of the unit through provision of guidance in the prevention of disease, non-battle injuries, and operational stress. Normally, routine sick call and the management of minor sick and injured personnel for immediate return to duty are a function of this level of care.
1612. Role 2 support is normally provided at larger unit level, usually of Brigade or larger size, though it may be provided farther forward, depending upon the operational requirements. In general, it will be prepared to provide evacuation from Role/Echelon 1 facilities, triage and resuscitation, treatment and holding of patients until they can be returned to duty or evacuated, and emergency dental treatment. Though normally this level will not include surgical capabilities, certain operations may require their augmentation with the capabilities to perform emergency surgery and essential post-operative management. In this case, they will be often referred to as Role 2+. In the maritime forces, Echelon 2 is equivalent to the land forces' Role 2+, as a surgical team is integral to this echelon. Maritime echelon 2 support is normally found on major war vessels and some larger logistics or support vessels, and at some Forward Logistics Sites (FLS).
1613. Role/Echelon 3 support is normally provided at Division level and above. It includes additional capabilities, including specialist diagnostic resources, specialist surgical and medical capabilities, preventive medicine, food inspection, dentistry, and operational stress management teams when not provided at level 2. The holding capacity of a level 3 facility will be sufficient to allow diagnosis, treatment, and holding of those patients who can receive total treatment and be returned to duty within the evacuation policy laid down by the Force Surgeon for the theatre. Classically, this support will be provided by field hospitals of various types. Maritime Echelon 3 is equivalent to land/air forces Role 3, though it will normally have increased specialty capabilities. Echelon 3 is normally found on some major amphibious ships, on hospital ships, at Fleet Hospitals, at some FLS, and at a few Advanced Logistics Support Sites (ALSS).
1614. Role/Echelon 4 medical support provides definitive care of patients for whom the treatment required is longer than the theatre evacuation policy or for whom the capabilities usually found at role/echelon 3 are inadequate. This would normally comprise specialist surgical and medical procedures, reconstruction, rehabilitation, and convalescence. This level of care is usually highly specialised, time consuming, and normally provided in the country of origin. Under unusual circumstances, this level of care may be established in a theatre of operations.


1605. Listed below are the principles of medical support that relate to operational support, from the NATO policy level to the planning constraints level.
  1. Authority. The medical resources provided by the nations are integral to the forces assigned to NATO. Under normal circumstances, nations must have first call on their own medical support. Units should deploy and re-deploy with a coherent medical structure tailored to their anticipated employment. However, the Force Commander must be authorized to take appropriate action in order to cope with casualty peaks within his force.
  2. Planning. Planning for medical support must be part of generic and contingency operational planning. Planning cells must include appropriate numbers of experienced medical staff supported by an operational medical intelligence system.
  3. National responsibility. Nations retain the ultimate responsibility for the provision of medical support to their forces allocated to NATO, but, on transfer of authority, the Force Commander will share the responsibility for the health and medical support of assigned forces.
  4. Required Medical Support. The medical resources required at the onset of any operation are those sufficient to collect, evacuate, treat and hospitalize casualties occurring at agreed daily rates. Factors such as geographical and military environment, climatic conditions, possible hostile interference and the availability of medical resources must be taken into account in the medical support concept and the planning process.
  5. Risk Related Planning of Medical Support. Medical capabilities must be in balance with the assessed risks to the deployed forces. The estimation of risks and the production of predicted casualty rates are the responsibility of the operational staffs.
  6. Statement of Requirements. The appropriate NATO Commander in consultation with contributing nations and medical planning staff is responsible for ensuring that the medical support requirements are fully met.
  7. Preservation of National Structures. National medical systems of care and evacuation should be retained as much as possible. However, advantages of economies of scale which could be accrued from multinationality and coordination of medical services should be realized whenever possible.
  8. Fitness and Health Standards. Individuals assigned to NATO operations must achieve, prior to deployment, the basic standards of individual fitness and health predetermined by national policy. Appropriate immun-isations must be given to all deployed personnel, as guided by medical intelligence estimate of the infectious health risks.
  9. NATO and National Cooperation. Coordination and cooperation between NATO and national military and civilian authorities is essential and must be carried out at all appropriate levels to ensure optimized medical support. Such cooperation can be bi- or multilateral, and should include the military and civil authorities not only of Alliance nations, but of Partner, host, and non-NATO nations as well.
  10. Commonality of Plans. Medical support concepts, plans, structures and procedures must be understood and agreed by all involved.
  11. Medical Support Expansion. Medical resources in theatre must be designed to provide, from the onset of the mission, sufficient capabilities to adequately provide all required levels of support. Medical support must expand progressively as force strength expands and risks increase and should have a surge capability to deal with peak casualty rates in excess of expected daily rates, understanding that the peaks will be beyond the capability to provide normal care.
  12. Readiness and Flexibility. Medical units and staff must be at the same state of readiness and availability as the force they support with the flexibility to meet the demands of evolving operational scenarios.
  13. Transition from Peace to Crisis or War. The medical support in crisis and wartime must originate from peacetime military health care systems by a progressive reinforcement. Medical readiness and availability must be sufficient to allow for the smooth transition from peacetime to crisis or wartime posture.
  14. Medical Materiel Readiness and Sustainability. Levels and distribution of medical materiel must be sufficient to achieve and maintain designated levels of readiness, sustainability and mobility to provide the required military capability during peace, crisis and war.
  15. Medical Standardization. National contingents should strive for standardization.
  16. Levels of Medical Support. Levels of medical support will be provided appropriate to each NATO operation but will include at least Role 1 to Role 3 in theatre.
    Role 4 facilities will normally not be located in an operational area. Medical staffs may promote the advantages of economies of scale from role specialization, lead nation responsibility and bi- or multinational agreements, but policies for national contributions will generally be:
    Role/Echelon 1 National responsibility
    Role/Echelon 2 National or Lead Nation responsibility
    Role/Echelon 3 National or Lead Nation responsibility (may be multinational)
    Role/Echelon 4 National responsibility or Bi- or Multi-national agreement
  17. Provision of Non-emergency Treatment. Policy must be established regarding the entitlement of non-military staffs and other authorized personnel for all non-emergency medical care.
  18. Definitive Treatment. Time consuming definitive treatment and rehabilitation will be provided under national responsibility, normally in a Role/Echelon 4 facility in the home nation.
  19. Mobility. Medical units must be as strategically and tactically flexible, mobile and responsive as the force they support.
  20. Medical Liaison. An efficient liaison system between national contingents and theatre medical resources must be established.
  21. Medical Supply Rates and Standards. National medical support contingents must deploy with agreed quantities of medical supplies as identified by medical planners and based on casualty estimates. Nations must use medical materiel, particularly blood and blood products, which meets internationally recognized quality assurance standards for the care of their patients. Policy and planning for the resupply of medical materiel must be developed in the planning process, making maximum use of multinational mechanisms.
  22. Evacuation Resources. Evacuation policy will be established by the operational commander after consultation with the medical planning staff and in concert with the operational and logistic staff and contributing nations. Evacuation resources must be provided by the nations as appropriate to a particular operation.
  23. Harmonized Management Procedures. The Force Commander will, in coordination with medical staff of participating nations contingents, establish harmonized procedures for the administration, management and reporting of medical support and casualty evacuation.

Medical support

Founded in 1994, the Committee of the Chiefs of Military Medical Services in NATO (COMEDS) is the Alliance's senior military medical body on military health matters. It acts as the central point for the development and coordination of military health standards and for providing medical advice to the Military Committee.


  • The COMEDS is NATO’s senior body on military health matters.
  • It aims to improve coordination, standardization and interoperability in the medical field and the exchange of information between NATO and partner countries.
  • It also develops new concepts of medical support for operations, with emphasis on multinational health care, modularity of medical treatment facilities and partnerships.
  • The COMEDS is headed by a Chairman and meets biannually in plenary session with representatives from NATO and partner countries.
  • The committee was established in 1994 when the need for coordinating medical support in peacekeeping, disaster relief and humanitarian operations became vital for NATO.
The COMEDS is a key component of the Alliance’s military health support system, principally in the preparation phase of an operation. It facilitates the development of medical capabilities in individual countries and helps to improve the quality and interoperability of capabilities between them. Generally speaking, the military health support system contributes to preserving the “fighting strength” and to meeting the increasing public expectation of an individual’s right to health and high-quality treatment.
Countries that allocate forces to NATO retain responsibility for the provision of medical support to their own forces. However, upon Transfer of Authority, the NATO commander shares the responsibility for their health and will determine the medical support requirements. The NATO commander usually has more responsibility for multinational arrangements.
The military medical community provides medical care, preventive health care and psychological support for deployed troops, as well as veterinary support for the animals that work with them. It also provides essential combat service support, making it one of the key planning domains for operations.

Roles and responsibilities

The COMEDS advises the Military Committee on military health matters affecting NATO and reports to it annually. It also acts as the coordinating body for the Military Committee regarding all military health-related policies, doctrines, concepts, procedures, techniques, programmes and initiatives within NATO.
In recent years, the COMEDS has come to represent the medical community at NATO Headquarters, in the NATO Standardization Office, as well as in specific areas such as defence planning and the chemical, biological, radiological and nuclear (CBRN) field.
The COMEDS’ objectives include improving and expanding arrangements between member countries for coordination, standardization and interoperability in the medical field and improving the exchange of information relating to organizational, operational and procedural aspects of military medical services in NATO and partner countries.

Working mechanisms

The COMEDS and the Chairman

The COMEDS is composed of the chiefs of the military medical services of all member countries, the medical advisor of the International Military Staff, and the medical advisors of the two strategic commands – Allied Command Operations and Allied Command Transformation. It is headed by a Chairman, who is elected by the committee in plenary session for a three-year period. The country of origin of the Chairman is also responsible for providing a Liaison Officer to NATO Headquarters, who is the Secretary of the COMEDS.

Meetings and their frequency

The COMEDS meets biannually in plenary session and includes participants from member and partner countries. It also benefits from the participation of the following observers:
  • the chiefs of the military medical services from all Partnership for Peace, Mediterranean Dialogue and Istanbul Cooperation Initiative countries;
  • the co-Chairman Health of the Joint Health Agriculture Food Group;
  • a representative of the NATO Standardization Office, the Military Committee, the Logistics Committee, the NATO Centre of Excellence for Military Medicine, the Human Factors and Medicine Panel of the NATO Science and Technology Organization and the CIOMR (Interallied Confederation of Medical Reserve Officers).
The COMEDS can also invite partners from across the globe, non-NATO troop-contributing countries and representatives from other organisations. It reports annually to the Military Committee.

Subordinate working groups

To assist in carrying out its tasks, the COMEDS has a number of subordinate working groups and panels which meet at least annually and address the following topics: military medical structures, operations and procedures (including planning and capability development); force health protection; military healthcare; standardization; CBRN medical issues; emergency medicine; military mental health; dental services; medical materiel and military pharmacy; food, water safety and veterinary support; medical training; military mental healthcare; medical naval issues; Special Operations Forces medical support and medical information management systems.

The Liaison Officer

The Liaison Officer is the point of contact for military health matters for NATO Headquarters and individual countries. For practical reasons, he/she cooperates closely with the medical branch of the International Military Staff, which also supports his/her work. The COMEDS also cooperates closely with the medical branch of Allied Command Operations (ACO) and Allied Command Transformation (ACT) in developments regarding defence planning, capability development, standardization needs, training and education and certification.


Historically, health matters within NATO were regarded strictly as a national responsibility so the Alliance did not possess a high-level military medical authority for the greatest part of its existence. However, with the Organization’s increased emphasis on joint military operations came the need for coordinating medical support in peacekeeping, disaster-relief and humanitarian operations. The COMEDS was therefore established in 1994.
Today, the COMEDS is very active in developing new concepts of medical support for operations, with emphasis on multinational health care, modularity of medical treatment facilities, and partnerships. Increasingly, the developed doctrines are open to non-NATO countries and are most of the time released on the Internet.
In 2011, the COMEDS established the COMEDS Dominique-Jean Larrey Award. This is the highest honour that the COMEDS can bestow. It is given in recognition of a significant and lasting contribution to NATO multi-nationality and/or interoperability or to improvements in the provision of health care in NATO missions within the areas of military medical support or military healthcare development The award is named after the French surgeon general of the Napoleonic imperial forces, who invented among other things the field ambulance, which helped to significantly improve medical care in the field

Further information

COMEDS Liaison Officer
NATO Headquarters
Logistics Resources Division
International Military Staff
1110 Brussels