Using Action Learning to study inadequate access to primary care medical services for deployed active-duty military personnel

Background: Military deployment and trauma-related stress can have a major impact on service women and men (active-duty, contractors, and civilians), making the need for not only acute but also primary health care a priority in the deployed environment. Yet, attention and resources focus mostly on acute care needs, resulting in gaps in access to primary care at various points in the deployment spectrum (pre-, during, post-deployment). This primary care access problem translates into unmet care and poor health outcomes.

Methods: We assembled a Coach-led Action Learning Team to study this problem from a systems-thinking perspective. We began looking at the problem within the overall context of the U.S. Military but narrowed our focus to Ramstein AFB, 86th Medical Group, Germany, where one teammate is stationed. Our Action Learning process, guided by the work of Senge, Checkland, and Marquardt, was iterative, consisting of individual- and group-work. The former included literature reviews, key informant interviews, and policy research, while the latter included sharing, discussing, and reflecting upon individual discoveries to advance our collective process. This allowed us to brainstorm as to how the factors under discussion would have given rise to the problem, as well as to identify potential leverage points for change in adopting adaptive solutions.

Results: Action Learning provided insights as to why deployed active-duty military personnel have inadequate access to medical care: (1) They have difficulty accessing primary care services, in part, because contingency contractors are utilizing these same services, resulting in a tragedy of the commons. (2) The contractors access these services primarily because of (a) medical necessity: Due to poor overall health, often exacerbated by nonexistent or inadequate pre-deployment screening, contractors need care in the deployed setting as a result of unidentified chronic health issues; (b) insufficient contract oversight: Because there is insufficient oversight, contractors are able to access care to which they are not entitled or (in cases of conditional entitlement) for which they are not providing the required reimbursements (to replenish the supply).

Discussion: Through Action Learning, we gained insights as to the root causes of the problem of inadequate access to primary care services for active-duty military personnel in the deployed setting. These insights informed proposed solutions: (1) Improvements in contract management, including enforcement of the reimbursement language in contingency contracts, must be made. (2) Pre-deployment health screening standards for contingency contractors, comparable to those for active-duty military personnel, must be implemented and met.