Organizational Implications of Long-Term Civil–Military Cooperation During COVID-19: A qualitative study

Benefits of Cooperation

Most study participants acknowledge that both organizations benefited from the collaboration. UMCU relied on the cooperation when it urgently needed external support to cope with the crisis situation, while the military had the ability to provide medical personnel on a short notice, which also improved the public image of the armed forces. For military personnel, involvement in the UMCU provided valuable working experience and contributed to the development of their (clinical) skills:

We have many young and new staff who have now gained experience in their own positions that they would otherwise never have gained. [R25-mil-deploy/staff]

It was also acknowledged by most interviewees on strategic level and also some at operational staff level that the COVID-19 collaboration enabled further cooperation and strengthened their resolve to formalize commitments for future joint activities. The Ministry of Defense now benefits from this partnership by the consolidation of new in-hospital training opportunities, while UMCU officially partnered with Defense as one of the 14 partnering hospitals (IDR) to expand its activities toward military medicine:

I think the collaboration during COVID has accelerated and strengthened a lot. [R14-civ-request]

Developing Doubts on the Distribution of Benefits

Mainly military respondents throughout strategic, tactical, and operational levels had their doubts if the effects of the collaboration were proportional beneficial for UMCU. The longer the collaboration lasted, the higher the degree of unease that was reported by these military respondents, but this was also recognized by a few civilian colleagues. For some, including an UMCU participant, the decision of UMCU to cooperate with the armed forces for extra personnel was perceived as a low-cost opportunity for UMCU:

We [UMCU] have benefited from that. Considerable financial benefit. If we should have hired people, regardless of where they would have come from. Or we should have spent money to have the part-timers work extra, or bonuses, or-. Now Defense has simply solved a very large personnel problem. [. . .]. The policy level was very happy with that of course. [R10-civ-deploy/staff]

This also raised the question on military tactical and strategic level if military support in the long term created false competition by disrupting the health care market at a moment on which there were possibly other options to scale up personnel capacity:

My other concern was: Defense is only there to absorb the initial blow, and after that, the institution has to take care of itself. [. . .] that’s just the non-compete clause for the initial emergency response. We’re there when there are real shortages, but once that’s resolved, despite the fact that there are still concerns. [R11-mil-request]

However, this sentiment related to the risk of financial exploitation was not recognized by all:

No, there is no competition. Because we did that already from a military tasking related to one of our core responsibilities. So in other words, there is not really any state aid. So there is also no Defense personnel deployed for elective care. [R33-mil-request]

We’ve always been very mindful of whether there’s a much higher return on this than what we’d normally do. That’s obviously not the case, because there’s also significantly less return on the care we’re not providing, because we were actually doing more than our fair share. So we did look into that, and we do monitor ourselves to see if there might accidentally be a positive business case for us. Because, of course, we simply didn’t want that from a societal perspective. [R18-civ-request]

Among study participants there was also a perception that apart from the common goal to cope with the patient flow, other organizational interests led UMCU to choose for civil–military collaboration too. A substantial part of mainly military respondents were increasingly convinced that, besides a strict financial advantage, deployed military personnel were used to solve a more common and already existing organizational problem of shortage of civilian medical personnel, rather than an acute problem, and an easy way to get extra personnel into the hospital. This observation was also made by an UMCU participant:

But in practice, everyone could manage it in their own region, but we still had support from Defense. So that did indeed give a bit of the feeling of, is that actually still for the country or is that for the UMCU? I can remember those conversations well, yes. At a certain point, it is also a bit over. And certainly in the departments, I think, you are just supporting care. Not solving the crisis. [R29-civ-deploy/nurse_physician]

Competing Priorities

During the ongoing collaboration, tension arose regarding competing organizational priorities. Initially, COVID-19 overwhelmed the hospital capacity, for which military support was brought in. UMCU agreed to the condition that the hospital would function as a national overflow capacity, which justified the extra military support to this hospital. It was also agreed that there would be no upscaling of regular care as long as military personnel was deployed at the hospital. At the same time, the military adhered to the agreement that the support would be available as long the numbers of COVID-patients were above a certain threshold. Over time, the situation became more manageable, but military support was still needed, because the hospital was not yet able to manage the situation without support. In fact, because of the remaining military support, referral of patients to the UMCU continued, maintaining its pressure on the hospital organization. While other hospitals started to upscale their regular care, UMCU was not able to do so because of the military presence at their hospital. The hospital was caught between conflicting types of interests. Despite the felt urgency to restart delayed medical care and a financial incentive to start treating regular patients, it was held back by an operational imperative to maintain military assistance:

And you gradually noticed, at a certain point it decreased again, that need for a national overflow capacity. But of course, we were still there. [. . .] I know that it really hurt a lot, those operating rooms down [in numbers]. Operations on children were cancelled, there were people sitting at that table of the senior management in the morning just crying about how distressing it was. And all hospitals in the region had that scaling down. And when the rest started scaling up again, the UMCU waited with that, because they had to do the national overflow. I also kept saying: pay attention, guys, keep doing that national overflow, because we are gone from here, this is the only justification for us being here. So if you wanted to stop that national overflow, that is not possible. Yes, that is possible, but then we are gone with those 150 people. [R12-mil-deploy/staff]

At the same time, the military faced its own competing priorities. At the beginning of the pandemic, military personnel was available, but military activities, such as training exercises and deployments, restarted over time. Medical personnel was needed for these military operational activities and military readiness was expected for international military commitments. The additional tasks of COVID-19 support caused a competition of priorities. Several military respondents stated that the COVID-19 support harmed the military operational readiness status and was felt long after the completion of the collaboration:

These are the same people who have been appointed to the VJTF [NATO commitment], which means that, when deployed, they lack the necessary knowledge to properly support their comrades in the forward area or to provide the care they deserve. So that long deployment has really been fatal for the ability and deployability of this unit. [R15-mil-deploy/staff]

However, some military interviewees also acknowledged that COVID-19 stretched the already existing challenges of military units due to years of financial cutbacks and reorganizations. Nevertheless, it shows that both organizations struggled with internal challenges as a result of the collaboration.

Integration-Distance Paradox

Another effect of long-term collaboration was managers’ fear that lower-level personnel at the workplace would overly identify with the collaboration partner. This could be a result of “too much integration” over time. This fear was particularly perceived at the military assigning level. There were concerns that, after a long period of collaboration, military personnel at UMCU felt responsible for the (negative) consequences when the decision was made to end the collaboration and leave the hospital. They worried that personnel would question the military decision and hinder a decisive exit. This concern was mainly countered by rotation of personnel, so personnel would be deployed for shorter periods of time. High rotation means that personnel had less chance to get fully acquainted with civilian partners and get attached to the collaboration. This policy was not explained by senior military decision-makers and therefore not understood at the workplace, where it caused frustration at the civilian side of the collaboration:

What you also see, is that your own staff, if you are somewhere for more than four weeks, then you also start to have an opinion about it. For more than two months, then you really start to get into the swing of things and after three months, your own coffee mug is in the department. And you just participate fully. And who do you work for here then? So yes, that took way too long. [. . .] And it’s not just at the decision-making level: OK, we’ll wait a bit. It’s also at the executive level that people are so involved and don’t want to get out of it either. [R28-mil-assign]

Moreover, a military manager explained that the military “is there to help, not to rescue” [R1-mil-assign]. This reflects some degree of conscious distance toward the collaboration and civilian concerns. The military, from this perspective, would not just blindly deliver what was asked for, but would deliver based on what problem needed to be solved and what the military had to offer in response, regardless of the initial request.

Military Support as a Last Resort

At the start of the crisis, the military was considered to be the only possible option to support the overwhelmed health care system (last resort). Because most military operational activities were canceled, a relatively large, well-trained source of medical skilled personnel became available on short notice:

And the advantage is that you [Defense] have trained healthcare personnel that are available, from that availability function. I think that is different from other places in the country, you don’t just have that. So you do have a contingent of professionals that can be deployed more freely than all kinds of other constructions that you had. [R18-civ-request]

But at the same time, mostly military respondents on tactical and operational level did question if the military was the only available and possible option. But even at strategic level, a military manager suggested that a request for military support was too much a default option:

Yes, you know, and that is also, a lot of unfamiliarity with other options that are there. But the first default response is: Defense. [R11-mil-request]

As the pandemic continued, the opinion grew that continuation of the collaboration was a result of path-dependency and previous success, rather than the military still being a last resort and the only available option:

But yes, what did you do yourselves to arrange it in the meantime? There were some options, VWS [Ministry of Health] volunteers for example. But for the rest, yes ok: if it happens then we [UMCU] press [the button] and they [Defense] will come. Because that is what they [UMCU] were used to. [R28-mil-assign]

Positioning, Priorities and Expectations

Among the military interviewees, there were different opinions on how the military should position itself in the face of this kind of collaboration. Most military respondents adhered to the concept of last resort for military involvement, although this principle was questioned by study participants throughout the collaboration at UMCU. Respondents also stated that this concept of last resort is not necessarily in conflict with a position of a strategic partner:

So you can sit and wait until you are the last resort, but then you are surprised, while otherwise you can be very prepared in where you intervene, or do not intervene, [. . .]. So I think that certainly at a strategic level, perhaps also at a high tactical level, you have to have those contacts very closely. And that you perhaps have a staff element that can contribute interdepartmentally. But I think it is different when you deploy [military] units for two years to do the execution. [R15-mil-deploy/staff]

Military respondents reflected also on the task of domestic support to civil authorities and the risk of competition with the two other military core responsibilities: (1) to protect national and allied territory, and (2) protection of the international rule of law. As emphasized by respondents from the request, assign, and deployment phase, it is a necessity for the military to be a strategic partner for civilian authorities in times of crisis. It should be able to deliver support as part of statutory obligations, at the request of civilian authorities. However, at the start of the pandemic, military resources were available due to downscaling of regular military activities. But what if this was not the case? A few respondents stated that expectations should be managed among civilian partners regarding the availability of military assets. Partners should always take into account that the military can also be deployed in the interest of these other core responsibilities. This means that in case of a next health crisis, military support might not be guaranteed:

With the size of our armed forces and what is happening in the world, we have to be able to do all three tasks at the same time. And the situation at that moment requires where the priority lies. Where in the pandemic, when there was no Ukraine yet, we also looked at whether we should consider stopping the other missions, to provide national support. But for example, if a pandemic breaks out again now, with no doubts we would ever think of immediately withdrawing that entire eastern flank again. [R11-mil-request]

Finally, both partners acknowledged the military’s added value in crisis support. But while the hospital was in urgent need of clinical support, the military regularly stated their expertise in crisis management, not primarily on COVID-19-related clinical skills. This reveals a difference in perspectives between the two partners concerning the perceived military’s optimal added value in this crisis collaboration:

You just notice that we as military personnel [. . .], we would do this so much more straightforward and clear and faster. That’s how we were raised. So that makes sense. [R12-mil-deploy/staff]

Occasionally, some discrepancy emerged between the expectations on the partnership. These did not escalate into a conflict between both sides, but the results of this study do show how important intra-organizational dynamics are for the stability and effectiveness of the interorganizational, civil–military collaboration.

Competing Priorities

This study shows that long-term collaboration took its toll on both collaborative partners. The military medical unit compromised on military readiness. The disadvantage in the state of operational readiness was clearly felt when, shortly after the COVID-crisis, a full-scale Russian invasion of Ukraine led to a war on the European continent and required international military commitments. For UMCU, the dilemma emerged at the moment it was not able to restart regular care, because of the military presence at the hospital. This caused frustration because of the delays in diagnoses and treatment, next to financial concerns. Even more because of UMCU’s highly specialized hospital care, which could not be taken over fully by local general hospitals. Furthermore, the financial concerns derive from the funding model of the Dutch health care system, which is built on marketization and financial arrangements with insurance companies, meaning that hospitals have targets to meet to receive full funding. European countries like Norway, Sweden, or Denmark have a much more centralized governmental funding model for health care, funded for over 80% by the national governments (Van Polanen Petel, 2022). This finance model might overcome the competitive incentives and financial concerns in times of crisis. Both dilemmas show that long-term collaboration does not necessarily become easier over time, as it can also come with a price for the organization itself and dilemmas might arise due to the long timeframe of collaboration. It is therefore important to regularly organize a re-evaluation of the settled agreements. This action should be added to the standing working arrangements to reserve space for flexibility within the collaboration and with the mutual acknowledgment and respect toward the organizational interests at stake.

When going deeper into the competing priorities of the military, it is important to keep in mind that armed forces have multiple tasks. The COVID-support was an urgent deployment in support of civilian authorities in times of crisis. However, military training and preparedness for more conventional military activities, to meet international readiness standards, is often seen as the most important role of the armed forces, even if there is no actual deployment (yet) (Kalkman, 2021). It helps to get a clearer idea of military priorities to be able to assess whether or not to accept the consequences of long-term domestic military deployments. It is even more important to get military priorities straight in this current time-frame of a shifting military focus toward warfighting in response to geopolitical changes at the borders of NATO territory. Moreover, it seems that the limited military resources are planned for dual use in two major international challenges. On one hand, global organizations call for pandemic response plans in which the military is expected to play a role (World Health Organization [WHO], 2021, 2024) and on the other hand, NATO leadership is asking allied countries to prepare for war (NATO, 2025). If military assets are a multi-use instrument, with deployments based on situational circumstances, it can be debated if and how the military can be a strategic partner for domestic crisis relief. A reliable strategic partner must be able to comply with binding agreements (Janse et al., 2022). At the same time, the military must be able to respond to different national and international unknown threats, dealing with limited available resources (Erickson et al., 2023). Prioritizing activities will be inevitable, while at the same time priorities can be revised quickly by situational changes. For the armed forces, this may complicate the adherence to binding civil–military commitments and agreements. From the point of view of civilian partners, this uncertainty in military commitment may be perceived as unpredictability of a partner, and might have implications toward their trust in the collaboration. Prioritizing military activities is a political consideration of the national government though. For successful collaboration in any civil–military activity, it is essential to make clear decisions on military priorities and specify limitations so both sides to the partnership know what to expect and can prepare accordingly.

Fear of “Too Much Integration”

While considerable civil–military differences are typically a challenge to crisis response collaboration in short-term, domestic deployments (Banks, 2006; Kalkman, 2019), there is a “risk” of too much integration in long-term partnerships. Our study shows that military planners at tactical level actively countered military personnel’s integration during the Dutch response to the COVID-19 outbreak. It adopted measures and policies to prevent the full social incorporation of military personnel in the civilian medical institution that it was supporting during the various COVID-19 waves. This surprising finding seems contrary to established ideas of collaboration. There is general consensus among scholars that successful civil–military cooperation requires integration. Civilian and military partners need to integrate functionally and socially to boost performance. This explains why researchers emphasize long-term stakeholder commitments and low personnel turnover (Forestier et al., 2016; Morgan et al., 2003; Morton Hamer et al., 2019; Wignjadiputro et al., 2020; Zottig et al., 2020). Such measures might help to bridge organizational prejudices and build trust between civilian workers and military personnel (Johns & Blazes, 2010). Vice versa, mutual unfamiliarity and short-term interventions breed distrust and hamper integration (Gibson-Fall, 2021). Ultimately, integration facilitates the exchange of knowledge, data, and expertise between civilian and military partners, thereby leading to improved coordination of activities and better results (Ma et al., 2016; McGee & Michael, 2020; Sanchez et al., 2011). But this perspective on integration shows a focus on interorganizational level of analysis, while it neglects the interests at stake for the individual organization within the collaboration, such as the military’s desire to maintain control over their own personnel and the perceived risk that military personnel might care more about civilian than about military concerns over time. Here, the hospital needed the military, not necessarily the other way around.

This shows the nature of the interdependency and also affected the balance of power within the collaboration. Successful interorganizational collaboration needs interdependency between participating organizations, and these participating organizations must be aware of this interdependency. They are aware that they cannot obtain their own goals without each other (Bollen, 2002). During the COVID-support, the military could have walked away out of the collaboration with less practical organizational harm than it would have given to the hospital. This might explain the decision to keep a level of control over personnel by making a decision that did not necessarily benefit the collaboration. Even more, the military could afford to make this decision, which might not be the case if the dependence is the other way around.

For instance, the current geopolitical tensions in Eastern Europe might develop into a conflict situation in which the military health care system cannot cope on its own. In that case, the military will be dependent on the national civilian health care system. Moreover, reserve personnel with a regular civilian job will be incorporated into the military organization, probably for a long period of time. Based on this study, it is important that military planners consider the interests of their civilian partners (e.g., hospitals) to ensure that diverging interests or dissatisfaction does not adversely affect the civil–military cooperation. From an alternative point of view, the civilian and military workforce can be seen as one large strategic resource of health care workers, that can be allocated flexibly depending on the (crisis) situation at hand. In fact, this may become necessary in case of an international conflict with overwhelming numbers of (military) patients.

Last Resort or First Responder

The concept of last resort often refers to the use of foreign military assistance (FMA) (UNOCHA, 2012). Nevertheless, the principle of last resort aligns with many countries’ domestic military support regulations. But the principle of last resort may not necessarily apply in a long-term domestic deployment, such as a public health emergency. The principle also initially applied to the national military deployment during COVID-19 in the Netherlands, although this positioning of last resort was challenged by some. The latter group of respondents perceived that the choice to call in the military was based on successful preceding deployments in national crises. This trend has also been identified in previous studies (Kalkman, 2019; Ratchev & Tagarev, 2018), but problematically, it can blur the line and increasingly render military deployment a quick fix for a broad range of societal challenges (Kapucu, 2011). It can be debated if the military support during the COVID-19 pandemic fitted the principles of last resort, or instead made the armed forces a first responder. Indeed, during COVID-19 pandemic, many national military armed forces acted as first responders rather than last resort (Boland et al., 2023; Erickson et al., 2023). Distinction between the two different approaches is important and has organizational consequences. A first responder organization has to be prepared for this formal task of short-notice deployments with little time for preparations in an emerging crisis. This demands pre-crisis arrangements, such as those described at the WHO guidance document for a national civil–military health collaboration framework. It entails the establishment of multisector strategic partnerships, acknowledgment of differences between the public health and military health services, identification of technical areas for health emergency preparedness collaboration, institutionalization of national civil–military health collaboration for preparedness and jointly building of capacities and training for health emergency preparedness (WHO, 2021). A last resort organization can uphold an approach of less involvement in a preparedness phase of collaboration. It can bring in resources as they are available on that given moment when all else has failed. In such a situation, the military can hold on to the principle that it can decide on the spot for what it can do in that given situation. This strategy is much more ad hoc-oriented. However, even this latter strategy can be explicated and included in national preparedness plans to manage expectations. Meanwhile, global health organizations call for the development of preparedness plans for the next pandemic (WHO, March 2024). At the same time scholars predict that in future (health) crises, national military assets will be deployed as a first responder more often (Boland et al., 2023; Erickson et al., 2023). A choice between strategies related to last resort or first responder asks for a political decision on military positioning on which the military and civilian crisis organizations can design their plans.