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Of the 1445 sources reviewed, a total of 43 publications met criteria for review. Six (13.9%) met empirical documentation criteria and 37 (86.0%) were considered nonempirical expert opinions and anecdotal accounts that were primarily descriptive in nature. Overall, disaster response accounted for 67.4% (29/43) and humanitarian assistance 25.6% (11/43). Public and private sector participants produced 79.0% (34/43) and 20.9% (9/43) of the publications respectively. Of private sector publications, 88.9% (8/9) focused on disaster response compared to 61.8% (21/34) from the public sector. Of all publications meeting inclusion criteria, 81.4% (35/43) focused on medical care, 9.3% (4/43) discussed partnerships, 4.7% (2/43) training, and 4.7% (2/43) medical ethics and strategic utilization. No primary author publications from the diplomatic, development, or participating host nations were identified. One (2.3%) of the 43 publications was from a partner nation participant. Discussion Without rigorous research methods yielding valid and reliable data-based information pertaining to Navy hospital ship mission impact, policy makers are left with anecdotal reports to influence their decision-making processes. This is inadequate considering the frequency of hospital ship deployments used as a foreign policy tool and the considerable funding that is involved in each mission. Future research efforts should study empirically the short- and long-term impacts of hospital ship missions in building regional and civil-military partnerships while meeting the humanitarian and disaster response needs of host nation populations.

Disaster preparedness is a comparative advantage of the Department of Defense (DoD) in the global health arena. It is in line with the domestic interest of sustaining foreign natural disaster assistance and the foreign policy interest of maintaining national security. The DoD humanitarian assistance policy guidance published in 2009 states Disaster Preparedness should be considered as a key priority in humanitarian assistance engagement. Unfortunately, a whole of government disaster preparedness program framework does not exist to facilitate effective and efficient implementation. Leveraging the United Nations Hyogo Framework for Action agreed upon by 168 nations to take action and reduce disaster risk by 2015, the DoD could synchronize disaster preparedness efforts with other interagency and international partners. Increased civilian-military cooperation in disaster risk reduction supports the whole of government approach to work in a more coherent manner in pursuit of shared foreign policy goals. It also maximizes the ability to deliver critical national capacity in the health sector and beyond. Disaster preparedness is an essential element of U.S. global health and foreign policy, and the DoD must be a critical partner in a whole of government approach.

The research finds the idea of building partnerships exists among most units of analysis. However, the results show a delay in downstream effects of generating action and impact among the participants. Without a common partnership definition and policy, guidance, and planning documents reinforcing these constructs, achieving the partnership goal will remain challenging. Efforts should be made to magnify the facilitators and enablers while developing mitigation strategies for the barriers and constraints. This is the first study to scientifically assess the partnership impact of hospital ship missions and could support the DoD's effort to establish, enable, and sustain meaningful partnerships. Application of the findings to improve partnerships in contexts beyond hospital ship missions may be warranted and require further analysis. This unique opportunity could bridge the rift with humanitarian actors and establish, enable, and sustain meaningful partnerships with the DoD.

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