Operation Desert Storm revealed many weaknesses in medical capabilities of U.S. forces. Subsequent studies conducted by us and the DOD Inspector General revealed shortcomings in DOD’s ability to provide adequate, timely medical support during contingencies and problems with the planning and execution of these efforts. The Joint Staff also identified problems with the current design of DOD’s wartime medical system. In response to these problems, DOD and the services embarked on initiatives to correct shortfalls in wartime medical capabilities and improve medical readiness. The decisions that emanate from these efforts over the next few years will determine how wartime medical care will be provided for the foreseeable future. In March 1995, DOD published MRSP to serve as a road map for attaining and sustaining military medical readiness into the 21st century. The Office of the Assistant Secretary of Defense for Health Affairs is responsible for managing MRSP. In developing its MRSP, Health Affairs convened panels of both military and civilian experts to assess medical capability shortfalls in nine functional areas: planning; requirements, capabilities, and assessment; command, control, communications, computers, and information management; logistics; medical evacuation; personnel; training; blood supply; and readiness oversight. For each functional area, the expert panels developed strategic objectives to support the continuum of military operations envisioned in the defense planning guidance for fiscal years 1996-2001. A total of 42 action plans were developed to address shortfalls in the 9 functional areas. In assessing these shortfalls, the panels relied heavily on the reports that we and the DOD Inspector General prepared on the medical reponse during Operation Desert Storm. The panels also identified the offices to be responsible for developing and executing detailed implementation plans. DOD is engaged in other efforts related to the wartime medical care system. Each service initiated a reengineering program to reassess and reconfigure its wartime medical capabilities to be more compatible with plans for two major regional conflicts and operations other than war. DOD is also trying to forecast the wartime medical demands in the year 2020 and design a military health services system that will be responsive to those demands (known as the MHSS 2020 project). In a separate effort, DOD is also updating an April 1994 study (known as the 733 update) to determine wartime medical personnel requirements for the year 2001. To respond to the new national military strategy resulting from the end of the Cold War and problems that we, the Joint Staff, and the DOD Inspector General identified, DOD initiated efforts to improve its wartime medical capabilities. Defense planning guidance, modified in May 1994, requires DOD to be ready to engage in two nearly simultaneous major regional conflicts and prepare for smaller scale operations other than war. DOD assumed that future operations would have far shorter warning times and durations than Cold War scenarios. The transition to the current defense planning guidance, particularly the projected shorter warning times, increased DOD’s emphasis on joint service operations and the need to react quickly to a major regional conflict or an operation other than war. This transition has also underscored the need for the services to redesign their wartime medical systems to reduce transportation demands because of limited lift capacity. Medical systems must compete with the movement of combat troops and other war-fighting materials to the theater. On the basis of war games conducted in December 1994, the Joint Staff determined that the commanders in chief were unable to provide adequate lift capability to move medical logistics and deployable hospitals to support two nearly simultaneous major regional conflicts. The Joint Staff recommended that the services investigate the possibility of evacuating casualties more quickly to the United States for treatment. The Joint Staff believed anticipated conflicts might be of such short duration that it would be unlikely that the soldiers would be well enough to return to duty after treatment in the theater. On the basis of war games completed in March 1995, the Joint Staff also recommended that the services approach medical operations from a joint perspective and redesign their medical systems assuming smaller and lighter deployable hospitals and quicker evacuation of patients to the United States for treatment. On September 30, 1993, the DOD Inspector General issued a report outlining several wartime medical problems that were consistent with Joint Staff observations. The Inspector General criticized DOD for a lack of joint medical planning. The report stated that DOD could not ensure the deployability of medical personnel during contingencies for several reasons, including outdated methods for determining personnel requirements, assignment of personnel to incorrect skill areas, and inadequate training of medical personnel. The report also stated that DOD’s deployable hospitals lacked sufficient mobility and had incompatible communication capability that limited their ability to prepare for incoming casualties. We have issued a series of reports that describe problems in DOD’s wartime medical planning and capability to provide wartime medical care. We found that understaffed and inadequately supplied and equipped medical units in Operation Desert Storm might not have been able to provide adequate care if the predicted number of casualties had occurred. Also, the medical units were not staffed and equipped to provide noncombat care and were unable to support the evacuation of casualties from the combat theater or receive large numbers of chemically contaminated casualties. Other medical force problems included (1) large numbers of nondeployable medical personnel due to unacceptable physical conditions, lack of required skills, and mismatches in medical specialties; (2) a widespread lack of training for the wartime missions; and (3) inadequate or missing equipment and supplies. In addition, we testified in March 1995 that several key factors, such as the population at risk and wounded-in-action rates, that affect the demand for wartime medical care were still being debated. We also stated that reaching agreement on the key factors was critical to arriving at the best wartime medical care system for the future, as it would allow decisionmakers to direct their attention to optimizing the medical care system for that demand. We reported in June 1996 that DOD was still having difficulty reaching agreement on such factors. Our comparison of problems highlighted by MRSP with those we, the Joint Staff, and the DOD Inspector General had previously identified shows that MRSP appropriately describes medical readiness problems needing resolution. The problems outlined in MRSP are also consistent with the recent changes in the Defense Planning Guidance. For example, MRSP points out that current medical planning is based on Cold War assumptions in which the services planned to fight the former Soviet Union individually rather than jointly. This lack of a joint approach made the DOD medical system unresponsive to the full continuum of anticipated contingencies, including major regional conflicts, peacemaking, and disaster relief. Accordingly, MRSP lists specific tasks Health Affairs, the services, the Joint Staff, and other DOD activities should take to ensure that joint medical planning becomes standard throughout DOD. MRSP also identifies the need for the services to modernize their deployable hospitals to reduce their weight and size. This reduction will decrease transportation demands and improve the mobility and transportability of such hospitals. It lists steps, such as incorporating technological advancements and equipment modernization, to correct these problems. Similarly, MRSP describes many factors that inhibit the deployability of medical personnel and lists steps to improve the training and certification of medical personnel to ensure they are adequately prepared to perform functions expected of them while deployed. MRSP outlines corrective actions to address problems in the communications area such as ensuring interoperability and adaptability of individual service medical communication with global communications systems. It also requires specific DOD offices to ensure the availability of critical medical materials needed for a conflict. MRSP also stresses the need for DOD and the services to reexamine and validate the key factors that affect the demand for wartime medical care. Three additional areas are currently being added to MRSP: nuclear, biological, and chemical warfare; operations other than war; and research and development. For each area, an expert panel identified capability shortfalls and developed corrective actions. Health Affairs plans to add these new areas to MRSP by December 31, 1996. Health Affairs got off to a slow start in monitoring progress being made in correcting medical readiness problems. The primary tool Health Affairs uses to monitor progress is its review of periodic updates of implementation plans submitted by the responsible offices. These plans summarize how and when a responsible office intends to correct a particular medical readiness problem described in MRSP. Although the implementation plans do not indicate the amount of funding involved, they describe whether specific corrective actions are fully or partially funded or unfunded. MRSP requires 400 implementation plans because of the multiple tasks and multiple offices responsible for carrying out needed actions. Initially, Health Affairs had difficulty obtaining complete implementation plans in a consistent format from the responsible offices. Although the offices were to submit the plans by the end of June 1995, Health Affairs had not obtained 19 (5 percent) of the required implementation plans as of April 30, 1996. The Joint Staff was responsible for six (32 percent) of the missing plans. A Joint Staff official said that staff turnover and competing priorities delayed the submission of the implementation plans but that they would be completed by the fall of 1996. The other offices responsible for the missing plans were Health Affairs, the Defense Modeling and Simulation Office, and the Office of the Assistant Secretary of Defense for Reserve Affairs. In commenting on our draft report, Health Affairs reported that it had obtained an additional 10 implementation plans, including all of the missing plans from the Joint Staff. Health Affairs also had difficulty collecting and analyzing the initial submissions because of the volume of information. Health Affairs corrected this situation by developing computer software to facilitate the quarterly updating and analysis of the implementation plans and sharing it with the responsible offices. In addition, Health Affairs entered into a contract with an outside firm to put the implementation plans on a computerized network so the responsible offices could continually keep them updated. This project is expected to be accomplished in December 1996. As a part of its monitoring efforts, in February 1996, Health Affairs convened most of the experts that helped develop MRSP to determine whether (1) the individual offices given responsibility for correcting medical readiness problems in MRSP were still appropriate and (2) the anticipated corrective actions described by those offices were responsive to the current readiness problems.