[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]



 
                         [H.A.S.C. No. 112-138] 
   ACCOUNTABILITY AND REFORM EFFORTS AT THE AFGHAN NATIONAL MILITARY 
                                HOSPITAL

                               __________

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED TWELFTH CONGRESS

                             SECOND SESSION

                               __________

                              HEARING HELD

                             JULY 10, 2012

                                     
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              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                    ROB WITTMAN, Virginia, Chairman
K. MICHAEL CONAWAY, Texas            JIM COOPER, Tennessee
MO BROOKS, Alabama                   ROBERT ANDREWS, New Jersey
TODD YOUNG, Indiana                  MARK S. CRITZ, Pennsylvania
TOM ROONEY, Florida                  COLLEEN HANABUSA, Hawaii
MIKE COFFMAN, Colorado
               Michele Pearce, Professional Staff Member
                 Paul Lewis, Professional Staff Member
                     Arthur Milikh, Staff Assistant


                            C O N T E N T S

                              ----------                              

                     CHRONOLOGICAL LIST OF HEARINGS
                                  2012

                                                                   Page

Hearing:

Tuesday, July 10, 2012, Accountability and Reform Efforts at the 
  Afghan National Military Hospital..............................     1

Appendix:

Tuesday, July 10, 2012...........................................    27
                              ----------                              

                         TUESDAY, JULY 10, 2012
   ACCOUNTABILITY AND REFORM EFFORTS AT THE AFGHAN NATIONAL MILITARY 
                                HOSPITAL
              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Wittman, Hon. Rob, a Representative from Virginia, Chairman, 
  Subcommittee on Oversight and Investigations...................     1

                               WITNESSES

Moorefield, Ambassador Kenneth P., Deputy Inspector General for 
  Special Plans and Operations, U.S. Department of Defense.......     5
Sedney, David S., Deputy Assistant Secretary of Defense for 
  Afghanistan, Pakistan, and Central Asia, U.S. Department of 
  Defense........................................................     2

                                APPENDIX

Prepared Statements:

    Moorefield, Ambassador Kenneth P.............................    38
    Sedney, David S..............................................    33
    Wittman, Hon. Rob............................................    31

Documents Submitted for the Record:

    News article submitted by Ms. Speier.........................    51

Witness Responses to Questions Asked During the Hearing:

    Ms. Speier...................................................    57
    Mr. Young....................................................    57

Questions Submitted by Members Post Hearing:

    Mr. Cooper...................................................    61
   ACCOUNTABILITY AND REFORM EFFORTS AT THE AFGHAN NATIONAL MILITARY 
                                HOSPITAL

                              ----------                              

                  House of Representatives,
                       Committee on Armed Services,
              Subcommittee on Oversight and Investigations,
                            Washington, DC, Tuesday, July 10, 2012.
    The subcommittee met, pursuant to call, at 3:04 p.m., in 
room 2118, Rayburn House Office Building, Hon. Rob Wittman 
(chairman of the subcommittee) presiding.

 OPENING STATEMENT OF HON. ROB WITTMAN, A REPRESENTATIVE FROM 
       VIRGINIA, CHAIRMAN, SUBCOMMITTEE ON OVERSIGHT AND 
                         INVESTIGATIONS

    Mr. Wittman. Folks, welcome.
    I want to call to order this Subcommittee on Oversight and 
Investigations of the House Armed Services Committee for 
today's hearing on Accountability and Reform Efforts at the 
Afghan National Military Hospital.
    I would like to welcome our witnesses here today: Mr. David 
Sedney, Deputy Assistant Secretary of Defense for Afghanistan, 
Pakistan, and Central Asia; Ambassador Kenneth Moorefield, 
Deputy Inspector General for Special Plans and Operations; and 
Major General Dr. Douglas Robb, the Joint Staff Surgeon, Office 
of the Chairman of the Joint Chiefs.
    Gentlemen, welcome today. We appreciate your taking your 
time to join us.
    We are looking forward to your testimony today, and 
Ambassador Moorefield, in particular, I would like to thank you 
for the work you have done on monitoring these issues. I hope 
you will let your team know how much this committee appreciates 
their noteworthy dedication to this challenging mission.
    Recently, I have traveled to Afghanistan and on a number of 
times over the past several years and have seen, particularly 
during my last trip in June, the great progress that has taken 
place since the surge has begun, a ways to go, but certainly 
significant progress to this point.
    And the key to sustaining this progress is building a 
capable Afghan National Security Force and, of course, the 
support systems to maintain it, including a medical care system 
responsible for the health and well-being of those who have 
served and sacrificed. Taking care of these troops is 
absolutely critical to this mission and must be a continued 
area of focus as we move forward.
    I am both disheartened and disgusted when I saw the 
pictures showing patient abuse and neglect at the military 
hospital, an institution where coalition forces serve as 
advisers and mentors. We can and must do better to ensure that 
these troops receive adequate medical care. Anything less is 
detrimental to our mission and compromises our efforts to 
secure Afghanistan's future.
    As I understand it, no one to date has been held criminally 
responsible for what happened. Moreover, there has been no 
accounting of the millions of dollars of funds and medical 
supplies that disappeared since these issues came to light. I 
hope you will provide us with explanations and detail the 
systemic reforms aimed at preventing this from happening again.
    As an administrative note, I recognize that members of 
other subcommittees will join us today. Pursuant to the 
committee rules, I ask unanimous consent to allow their 
participation. And absent objection, I will recognize them 
after all O&I Subcommittee members have had an opportunity to 
question the witnesses.
    Gentlemen, thank you again. We look forward to your 
testimony and taking our questions.
    And with that, I will turn it over to our ranking member, 
Mr. Cooper.
    [The prepared statement of Mr. Wittman can be found in the 
Appendix on page 31.]
    Mr. Cooper. Thank you, Mr. Chairman.
    I have no opening statement. I look forward to hearing the 
testimony of the witnesses.
    Mr. Wittman. Thank you.
    Mr. Sedney, we will begin with you.

  STATEMENT OF DAVID S. SEDNEY, DEPUTY ASSISTANT SECRETARY OF 
   DEFENSE FOR AFGHANISTAN, PAKISTAN, AND CENTRAL ASIA, U.S. 
                     DEPARTMENT OF DEFENSE

    Mr. Sedney. Thank you very much, Mr. Chairman and members 
of the subcommittee.
    And I particularly thank you, Mr. Chairman, for your 
attention to this very important issue and for the continuing 
interest and effort that you have put into this area, which you 
have very aptly described the importance of.
    I appreciate the opportunity to be before you and the 
members of the subcommittee to discuss Afghanistan and 
particularly the efforts towards accountability and reform at 
the Dawood National Military Hospital in Kabul, Afghanistan.
    I want to start off by going back to basic principles here, 
which is why are we there? Why are we concerned about 
Afghanistan and the Afghan National Security Forces and, 
therefore, the hospital?
    The United States, together with our coalition allies and 
our Afghan partners, is dedicated to our core objectives in 
Afghanistan of disrupting, dismantling, and defeating Al Qaeda 
and its extremist affiliates, to deny them safe haven from 
which they can launch attacks against the United States and our 
allies and partners, and to deny the Taliban the ability to 
overthrow the Afghan government and re-create such safe havens.
    Thanks to more than 10 years of dedication and sacrifices 
by our forces, our coalition partners, and the Afghan people 
themselves, we have taken enormous strides towards achieving 
those objectives, particularly over the last 3 years.
    A key objective, the key objective to achieving this 
strategy is the development of the Afghan National Security 
Forces into a sustainable and capable force. Their growth and 
confidence and demonstrated capability to provide suitable 
security against internal and external threats are essential 
for the responsible transition of security in Afghanistan to 
the Afghans themselves by the end of 2014, as agreed to by NATO 
[North Atlantic Treaty Organization] heads of state at Lisbon 
in 2010 and reinforced by NATO heads of state at Chicago last 
month.
    To this end, with coalition support, the Afghan security 
forces have made great progress, both in terms of size and 
capability. Both the Afghan National Army and the Afghan 
National Police are on schedule to meet their surge end-
strength goals of 352,000 by or before October of this year.
    Their continued performance and ability has allowed them to 
move increasingly into the lead for operations, including in 
operations in recent days and weeks in countering major attacks 
in Kabul, in Kandahar, Helmand, and elsewhere. Currently, the 
Afghan security forces participate in over 90 percent of all 
coalition operations, and more than 50 percent of these 
partnered operations are led by the Afghan security forces.
    In addition to the success of the Afghan security forces 
that I mentioned, I want to stress to the committee the 
importance of two signal achievements that have sent an 
important signal to the Taliban, the Afghan people, and to 
countries in the region.
    The first is the strategic partnership agreement that 
President Karzai and President Obama signed in May that shows 
the United States and Afghanistan are committed to a mutually 
beneficial relationship beyond 2014.
    Second, as I mentioned before, the Chicago summit was a 
great success and demonstrated the continued dedication of over 
50 NATO and other partner nations to supporting security and 
stability in Afghanistan. They reaffirmed their commitment to 
the Lisbon timeline but, very importantly, agreed to continue 
their commitment after 2014.
    Despite these achievements, there are still many areas that 
need improvement. Many, many areas. Particularly, in the Afghan 
security forces, it is important to have improvements for them 
to be the independent force that they need to be in 2014 to 
protect Afghan security.
    One of the key areas, as you have said, Mr. Chairman, is 
the development of a medical system capable of sustaining the 
health and well-being of the Afghan security forces. The 
allegation raised in the past years, particularly in 2010, of 
mismanagement at the Dawood National Military Hospital 
highlighted gross deficiencies in the system and the critical 
need for serious reforms.
    Coalition medical mentors and advisers reported inexcusable 
mismanagement and, at times, neglect in the operation and 
provision of basic medical care, resulting in substandard 
patient care, disturbing sanitation conditions, poor facilities 
management, and a dysfunctional medical logistical system.
    These concerns were elevated to senior leaders in the NATO 
Training Mission-Afghanistan [NTM-A] and to its commander at 
that time, Lieutenant General William Caldwell.
    Recognizing the enormity of the situation, General Caldwell 
took action. He requested the involvement of the Department of 
Defense Inspector General [IG] Office of Special Plans and 
Operations to assess the nationwide medical logistics system in 
Afghanistan.
    With regard to the substandard patient care concerns, 
Lieutenant General Caldwell's staff alerted the IG and his 
staff to those concerns, and the IG expanded the scope of its 
oversight activities to include reports on this matter.
    Thanks to the response and effort in reforming the 
healthcare and medical systems, we are now helping to turn 
around what had been a broken system, introducing 
accountability, standards, and stewardship at all levels.
    The senior leadership of ISAF [International Security 
Assistance Force] NTM-A and the medical advisory group 
recognized the critical importance of enabling a system that 
could provide adequate healthcare to the Afghan security forces 
now and for a transition to take place in 2014. Improvements in 
the accountability of the changes in and improvements in the 
hospital leadership and staff, the general sanitation 
standards, the standard of patient care, and the logistics 
systems are underway.
    Following the removal of General Ahmad Zia Yaftali from his 
position as hospital commander, new leadership established more 
stringent planning and oversight to advance the professional 
conduct and accountability of the medical staff, with special 
attention towards combating staff absenteeism.
    By last summer, NTM-A mentors reported that a new hospital 
commander, chief of surgery, and chief nurse routinely 
intervened in every case of possible neglect. And by August of 
last year, there were no known cases of neglect.
    Follow-up inspections in 2011 showed marked improvement in 
cleanliness, dressing, and sterilization. The transfer of 
medical logistics from the Office of Surgeon General to the 
Logistics Command allowed the Ministry of Defense to enforce 
its own standard controls over receipt, storage, 
accountability, and distribution of pharmaceuticals and other 
supplies.
    Newly implemented medical inventory and tracking systems at 
Dawood have introduced greater transparency and efficiency in 
the supply chain management. The Logistics Training Advisory 
Group and Medical Training Advisory Group conduct continuous 
battlefield circulations throughout the hospital to provide 
daily follow-up and ensure compliance.
    These are just a few of the examples that I have been made 
aware of. If you have further questions regarding these recent 
improvements, we look forward to addressing them in Q&A.
    NTM-A, the coalition forces, and the leadership, starting 
with General Allen, remain committed to continuing this 
progress and supporting our Afghan counterparts as they display 
increasing capability and growing responsibility and 
improvement. The conditions which existed before have changed. 
A lot more remains to be done, but we are committed to the 
sustained improvement necessary for Afghanistan to have that 
enduring capability that you described, Mr. Chairman.
    Again, I would like to thank you and the members of the 
subcommittee for the opportunity to appear before you and look 
forward to your questions.
    [The prepared statement of Mr. Sedney can be found in the 
Appendix on page 33.]
    Mr. Wittman. Thank you, Mr. Sedney.
    I appreciate your comments to begin with, but I would like 
to recognize Representative Mike Coffman from Colorado for his 
tireless advocacy to make sure that this issue with Dawood 
Hospital would be addressed. So, Mr. Coffman, I appreciate your 
efforts here.
    And with that, Ambassador Moorefield, we will turn to you 
for your opening comments.
    I want to remind, too, the witnesses that as much as we 
can, we like to try to stick to the 5-minute timeframe. Your 
comments will certainly be entered for the record in their full 
content.

STATEMENT OF AMBASSADOR KENNETH P. MOOREFIELD, DEPUTY INSPECTOR 
 GENERAL FOR SPECIAL PLANS AND OPERATIONS, U.S. DEPARTMENT OF 
                            DEFENSE

    Ambassador Moorefield. Thank you, Mr. Chairman and Ranking 
Member Cooper and distinguished members of the committee and 
subcommittee.
    Thank you for this opportunity today to discuss OIG 
oversight of the Department's efforts to develop the Afghan 
National Security Forces [ANSF] healthcare system and also the 
developments at the National Military Hospital.
    The development of the Afghan National Security Forces has 
included, as Dr. Sedney said, building an effective healthcare 
system to support field-level combat casualty care, evacuation 
of wounded casualties, restorative surgery, and long-term care 
for disabled personnel.
    Meeting this challenge has understandably proven difficult. 
When the ANSF medical care system development efforts began, 
the country's public healthcare system was rated among the 
worst in the world by international experts. The remnants of 
the Soviet era military medical facilities and services left by 
the Taliban had further deteriorated this limited capability.
    But given the importance of the medical care issue, 
therefore, as it relates to the Afghan security forces, DOD IG 
[Department of Defense Inspector General] has undertaken a 
succession of oversight initiatives since 2008 and up to the 
present.
    Our assessments in 2008 and 2009 determined that the 
complex set of issues related to medical stabilization and 
reconstruction challenges in Afghanistan called for a robust 
U.S. and international effort to develop and implement a 
multiyear planning strategy.
    Many U.S. military medical mentoring teams at that time 
with whom our teams met were not appropriately staffed. The 
development of ANSF medical personnel was seriously hampered 
also by inadequate guidance to U.S. medical mentors, 
particularly regarding standards objectives.
    Our 2009 assessment recommended that the U.S. Training and 
Advisory Command develop a clearly defined plan for building 
the ANSF healthcare system in coordination with the relevant 
Afghan ministries and security forces. In 2010, at the request 
of the Commander, NTM-A CSTC-A [Combined Security Transition 
Command-Afghanistan], we assessed the Afghan army medical 
logistics system, which included the National Military 
Hospital.
    We made recommendations for strengthening the system, 
including improved accountability and control of medical 
supplies. We also determined that ANSF healthcare system 
planning did not include a defined end-state goal, and the 
mentoring effort was impeded by only having half the authorized 
medical mentor personnel.
    In February 2011, we conducted an inspection of just the 
National Military Hospital. This mission was precipitated by a 
report received by our IG who was on a tour of Afghanistan and 
in Kabul in November 2010.
    During this mission, our team identified issues related to 
inadequate Afghan medical personnel staffing at the hospital, 
failure of the logistics system to reliably deliver 
pharmaceuticals to the hospital and the hospital to its 
patients, significant quantities of unused medical equipment 
and supplies, inadequate patient nutrition, and a lack of 
clearly defined medical standards, among other issues.
    We subsequently carried out an audit of the pharmaceutical 
distribution system. The team found that although the process 
had made progress in the previous year, the delivery and 
inventory control processes for pharmaceuticals in particular 
at ANA [Afghan National Army] medical facilities and depots 
required further improvement.
    Just 2 weeks ago, in this past June, a DOD IG team returned 
to the NMH [National Military Hospital] to review the status of 
efforts to improve its management, healthcare services, and 
logistical support. As is customary, our team outbriefed our 
military command and the National Military Hospital leadership 
and staff prior to its departure.
    There were 15 U.S. military mentors present at the NMH 
during this inspection. The team noted that since our February 
2011 inspection of the NMH, progress had been made in a number 
of areas. This is further detailed in my written testimony.
    Key among these areas were no complaints or evidence of 
patient maltreatment; new processes and procedures to improve 
personnel accountability and patient care, including for 
nutrition; clearly defined medical standards; improvements in 
the medical logistics system; and improved leadership by the 
ANA medical command and at the NMH itself.
    Also, ISAF, the International Security Assistance Force, 
and NTM-A have now published an ANSF healthcare development 
plan, identifying the readiness performance criteria for the 
NMH to be able to meet the NTM-A transition objective of Afghan 
assumption of lead responsibility for their functioning by the 
third quarter of 2013.
    Our team observed substantial NMH progress towards 
achieving this objective. Once achieved, the NTM-A intends to 
continue to provide mentor monitoring of the NMH performance 
and the rest of the healthcare system through 2014.
    There is still some NMH development challenges remaining. 
These include personnel shortages, specifically at the pharmacy 
and nursing departments, the transfer of ANA patients from 
coalition medical facilities to the NMH. NMH requires better 
coordination. Inventory control procedures have improved in the 
bulk storage area but need to be implemented in the dispensary, 
and the NMH staff needs additional training.
    Finally, NTM-A is still working to identify the scope of 
its support for a post-2014 ANSF healthcare development mission 
intended to enable its enduring sustainability.
    In closing, let me emphasize the DOD IG remains committed 
to providing oversight of U.S. and coalition efforts to develop 
further the Afghan military healthcare system, including at 
NMH. And we thank you for this opportunity to speak to you 
today, look forward to any questions you may have.
    [The prepared statement of Ambassador Moorefield can be 
found in the Appendix on page 38.]
    Mr. Wittman. Thank you, Ambassador Moorefield. We 
appreciate your opening testimony.
    Major General Robb, I understand that you do not have 
opening testimony, but that you will be available to answer 
questions from committee members.
    Thank you so much for joining us today.
    With that, Mr. Sedney, I will begin with you. I want to 
focus on the former surgeon general there in Afghanistan, Ahmad 
Yaftali. And as you know, allegedly, he profited from missing 
medical supplies there at the hospital and failed to address 
some fairly serious neglect issues there at the hospital, in 
some cases leading to people dying at the hospital.
    And based on that, my question is, is he still under 
investigation by our folks there in theater? Is he still 
wearing a uniform? And are U.S. or coalition force dollars 
still being expended to pay his salary?
    Mr. Sedney. Mr. Chairman, we are very much aware of the 
serious allegations against General Yaftali, and there is 
currently an ongoing investigation. It is an Afghan 
investigation under Afghan law, carried out by Afghan 
authorities.
    However, the U.S. Department of Defense, particularly 
through Task Force Shafafiyat (Transparency) at ISAF, are 
giving support to that investigation. We are conveying 
accurately to the Afghan authorities all the information that 
we have, working with them to develop additional information 
where it may be needed for the possible--or for any possible 
charges that may be brought.
    Well, you are correct. No charges have been brought against 
General Yaftali or anyone or others involved in this. I can 
assure you that this is a very serious effort. It is supported 
and monitored at the top levels of our leadership structure in 
Afghanistan and here in Washington and that we believe that 
this investigation will result in--that it will result in a 
very close look at all the allegations.
    We can't prejudge whether there will be charges, whether 
there will be convictions, and what the fate of any individual, 
including General Yaftali, will be. In fact, we have to be 
careful not to try and make statements that will presuppose a 
particular outcome in the Afghan judicial system.
    But as I said, I can assure you that the investigation is 
ongoing. It is serious and receiving a lot of assistance from 
the U.S. authorities.
    Mr. Wittman. Just to reiterate the question, is he still 
wearing a military uniform, and are any U.S. or coalition funds 
being expended to pay his salary currently?
    Mr. Sedney. General Yaftali was removed from the leadership 
of the hospital. To our knowledge, he does not have another 
position inside the Afghan forces.
    Whether he is receiving his salary or not is a question 
that we will ask the Afghans, but we don't have any information 
to say that he is not. However, any disciplinary action that 
would be taken against him would come out of this ongoing 
investigation. So I am going to be careful not to say anything 
that will prejudge what that investigation might or might not 
result in.
    Mr. Wittman. Thank you, Mr. Sedney.
    Ambassador Moorefield, your June 2011 report outlined a 
number of significant shortcomings that continue to exist in 
areas of planning and execution of a medical logistics system 
there within the Afghan medical system. And you said there that 
the current system could not be maintained without continued 
U.S. and international support.
    How long do you think this condition will continue to 
exist, and what other areas of medical care system pose similar 
challenges there in Afghanistan as we speak?
    Ambassador Moorefield. Okay. I think I got it this time.
    Thank you, Mr. Chairman.
    The planning that is currently going on, and this is 
according to our team's report--and they just came back a few 
days ago and spent extensive amount of time with the command--
is that beginning at the end of 2013, after the third quarter 
of the calendar year, they are going to transition to lead 
responsibility to the Afghan medical personnel at all the 
hospitals and the depots with the intention of monitoring their 
performance through 2014.
    And where intervention and support and additional mentoring 
is required, be able to provide that. But essentially, transfer 
the burden of that responsibility and, therefore, the need for 
them to take appropriate action on their own hook. So that is 
the intention through 2014.
    Now I believe that the healthcare system has been 
identified as an ongoing responsibility, support responsibility 
of our command, along with several other key enabling function 
areas. I understand that even though we don't have the 
specifics of the plan, which I mention in my remarks and we 
hope to get soon--they are still working on it--but in any 
event, after 2014, we think the emphasis is going to be 
primarily on training and education. And this is where they 
seriously need additional assistance to help build a base, 
basically, for an enduring and sustainable Afghan military 
medical system.
    And this could include a whole range of activities. There 
is medical training that is going on right now, but that base 
will be, we understand, expanded up to and include even 
fellowships and residencies for doctors in specialty care areas 
that would be undertaken in the country.
    Mr. Wittman. Thank you, Ambassador.
    With that, we will go to our ranking member, Mr. Cooper.
    Mr. Cooper. Thank you, Mr. Chairman.
    I am worried that the interface between U.S. personnel and 
the Afghan so-called health system puts U.S. personnel in an 
impossible situation. Because to read one of the documents 
here, the MTAG [Medical Training Advisory Group] staff mentors 
and advises the Afghans, but they do not treat patients, 
prescribe, or otherwise administer vaccines or pharmaceuticals.
    Their purpose is ``to help the Afghans perform and to 
increase their capability, not by doing for them but rather by 
advising them and stepping back. They perform not as a 
clinician, not as a nurse, not as a technician, but as a 
trainer. When they come here, it is advising.''
    But this is an interface between the most advanced society 
on the planet and Fourth World medicine. How on earth do you 
advise when doctors and nurses so-called in Afghanistan don't 
show up, don't feel an ethical duty to treat the patient? Let 
them, in some cases, starve to death or steal their medicines 
or let bedsores kill them.
    These are unspeakable conditions, but then this is a 
country without reliable power, without so many of the things 
that we take for granted in this country. How on earth could 
anybody advise in that situation? It is a guaranteed nightmare.
    So I am not excusing any of the, by our standards, bad 
behavior in Afghanistan, but we can't change the whole country. 
And you wonder if we are fighting side by side with ANSF forces 
and our folks get first-rate, First World medicine, the most 
advanced battlefield medicine in the world, and some of these 
folks go to their so-called hospital, you would almost rather 
take a bullet than die of sepsis in one of these places.
    But furthermore, in addition to putting U.S. personnel who 
are tasked with this impossible job of advising this hospital, 
I am worried that this puts you gentlemen in an impossible 
situation. Because you don't want to upset the Afghan 
relationship, and we know that it is a deeply corrupt country. 
We know that their culture in so many ways jars with ours.
    And in terms of standards of care, to my knowledge, they 
haven't defined hospital services. So when we apply a Western 
lens to this, aren't we kind of fooling ourselves? And I am, 
again, not excusing any of the bad behavior over there, but how 
on earth do you drain this swamp?
    We have no ability to compel the Afghan doctors to show up, 
to make them do right when they are there, to even sterilize 
their hands or instruments. So how do you administer care or 
how do you advise on administering care in that situation? This 
is the worst nightmare a health provider could ever possibly 
imagine to even be associated with that, without any control.
    How do you fix it? All you do is get tainted by whatever 
you are associated with. So, again, I am not excusing any bad 
behavior. I wish they would do right. And when you wonder about 
if somebody is being paid, the entire Afghan economy is 
subsisting off of the U.S. and Western taxpayers.
    So whether it is directly or indirectly, unless it is their 
feeble internal production or the opium poppies, where else 
does their money come from unless it is from the West? This is 
why this is the second-poorest country in the world.
    So I want to get to the bottom of this, and I am not making 
any apologies for General Yaftali, but for U.S. personnel to 
come in or alliance personnel to come in and try to fix this, 
how do you go about that without any control in a purely 
advisory capacity? What is the answer here, other than to put 
good U.S. personnel in an impossible situation?
    I have 49 seconds left if anyone wants to respond to that.
    Mr. Sedney. I will say a quick word, Representative Cooper. 
You have laid out the challenges. Those challenges existed when 
we went into Afghanistan 11 years ago. And as Ambassador 
Moorefield pointed out, Afghanistan had about the worst 
healthcare system in the world.
    There has been a lot of progress. A week ago today, I was 
in Kabul. I met with a number of students from the American 
University of Afghanistan. They are well aware of the 
challenges that their country faces, and they are taking them 
on and moving forward.
    Our advisers--and if we had time later, maybe General Robb 
can talk about the ethical quandaries that you mentioned. But 
the advice and assistance that we have been providing over the 
last 10 years is resulting in the kind of improvements that 
Ambassador Moorefield mentioned.
    Is it a daunting challenge, as you have described it? Yes. 
Is it an impossible challenge? We don't believe so. Will it 
require continued effort even after 2014? Yes, and that is why 
we are committed and our NATO allies and partners are committed 
to continuing that effort.
    But you have laid out very clearly the challenges. But I 
think the Afghan people working with us see a way forward 
despite those difficulties.
    Mr. Wittman. Thank you, Mr. Cooper.
    We are going to go now to Mr. Young.
    Mr. Young. Thank you, Mr. Chairman.
    And I thank all our panelists for being here today. Thank 
you for your testimony.
    Ambassador Moorefield, you had discussed at some length the 
adviser/mentor program, and you talked about that. I would like 
to dig a little deeper on that. Before I do, cite Lieutenant 
General Caldwell, who mentioned underresourcing and staffing as 
significant barriers to any further success we would see at the 
hospital there and, thus, I would say by extension barriers to 
achieving an independent force, as we look into the future.
    Since Lieutenant General Caldwell made that statement, what 
improvements, if any, have we seen in an adviser/mentoring 
program trying to train more personnel in medicine? And is this 
adviser and mentor role, is it sustainable as we consider 
pulling forces out after 2014? With the understanding there 
will still be some support role for our forces, but will that 
in any way undermine our capability to strengthen the 
capabilities at this hospital and other medical facilities?
    Ambassador Moorefield. Thank you, Congressman Young.
    The challenge is going to be ever-present for the immediate 
future as to whether or not they are going to be able to pick 
up the ball and run with it. I think that the command has a 
good game plan, and that is that they are not going to just 
give them the ball and walk away off the playing field.
    They are going to be there to continue to monitor their 
performance and intervene as appropriate and necessary along 
the way. So there is a reasonable degree of confidence, and let 
me just talk about the National Military Hospital.
    There are standards now. One of the big problems that we 
had identified in our work previously was in the absence of 
standards, it was very hard for our mentors to know what to do 
and for the hospital personnel either there or in the regional 
hospitals to know exactly what is it that we are trying to 
create here. What is the standard? What is the capability?
    Considerable work has been invested in the last few years 
in developing Tier 1, Tier 2, and Tier 3 standards, and there 
is every expectation they will erase the Tier 1 standard, which 
is the objective by the third quarter of 2013. That standard 
has a whole series of requirements that are inspected on a 
quarterly basis now by our command and by the Afghan command. 
And they have made substantial progress.
    Let me just quickly if I can say something about the 
regional hospitals. I realize the focus has, more often than 
not, been on NMH of late. But our work, which has included all 
of the hospital system in the Afghan security forces, including 
the ANP [Afghan National Police] hospital, has indicated the 
regional hospitals have actually--had actually made 
considerable progress that was not so visible because it is out 
there in the regional commands.
    And indeed, I think have been very impressively moving 
forward, although even with greater speed and efficiency now 
that they have defined standards. The NMH was a lagging issue, 
and considerable progress has been made.
    You mentioned, Congressman Cooper, that there were issues 
related to not showing up at work. That is absolutely the case. 
This is my own personal opinion, but I think leadership was a 
major factor. And now that the leadership has dramatically 
shifted in the right direction at the NMH, they are enforcing 
the standards of showing up for work and doing your job.
    And those individuals--and there have been recent cases--
who did not do their jobs have found themselves at the wrong 
end of administrative sanctions. So going back to your original 
question, I think there is a reasonable chance that if we 
continue there with them, shoulder to shoulder, so to speak, 
they will get to where they need to get to.
    Mr. Young. I have got 30 seconds left, Mr. Ambassador. But 
you indicated that there was progress, measurable progress 
based on the standards that have been set and the measurements 
as compared to those standards. Seeing as you have had access 
to these reports and what-not, could Congress get access to 
these progress, quarterly progress reports?
    Mr. Sedney. I think that is certainly a very reasonable 
request, and we will get back to you on that with a definite 
answer.
    Mr. Young. Thank you.
    Mr. Wittman. Thank you, Mr. Young. We appreciate it.
    Mr. Sedney, if you could follow back up with that and let 
the committee know when and how those reports would be 
available, we would like to have them for the committee 
members.
    Thank you.
    [The information referred to can be found in the Appendix 
on page 57.]
    Mr. Wittman. Thank you, Mr. Young. We will now go to Mr. 
Brooks.
    Mr. Brooks. Thank you, Mr. Chairman.
    Just a quick background information. How much of the 
funding for the Afghan National Military Hospital comes from 
the United States? Do you have a judgment as to the percentage 
or the quantity, any of the three of you?
    Mr. Sedney. What I can tell you, Representative Brooks, is 
we have spent about $185 million over the past 9-plus years on 
the Afghan military medical system, and to the best of my 
knowledge, that has been virtually the only source of funding 
for it during that period of time.
    There have been occasional efforts by other countries that 
have resulted in small amounts of--much smaller amounts of 
money. So I can't say with certainty that all of the support 
for the National Military Hospital come from the United States, 
but the vast majority of it has.
    Mr. Brooks. So that, I am sorry?
    Mr. Sedney. That $185 million is for the entire military 
medical system, of which the military hospital is only part of.
    Ambassador Moorefield. I would just add that, of course, 
there have been international donations, notably by Japan, in 
terms of equipment and supplies. In addition, the training and 
education has been very significantly impacted by coalition 
forces. And for example, next to the National Military Hospital 
is the medical university, and the program there has between 20 
and 30 Canadian personnel that are responsible for training 
physician's assistants and medics and medical technicians.
    That is true also up in the north, where the German command 
is located. So if you look at the overall effort, it is not 
just our funding. But I think specifically related to funding 
for equipment and supplies, that has been largely a U.S. 
contribution.
    Mr. Brooks. As America shifts more of the fight 
responsibility from American troops and allies to the Afghans, 
do you anticipate that the medical facility costs will go up?
    Mr. Sedney. Trends right now are that the Afghan security 
forces are suffering casualties in their last 2 months at a 
somewhat increased level, at an increased level than we would 
expect. As they move more and more into the lead, there will be 
more Afghans who are wounded and require medical care in their 
facilities.
    So, yes, we would expect those costs to go up and the need 
for care to increase.
    Mr. Brooks. Do you have a judgment as to how long it will 
be before the Afghan economy is strong enough to take over the 
responsibility of funding the cost of the Afghan National 
Military Hospital?
    Mr. Sedney. For the Afghan security forces as a whole, the 
NATO heads of state meeting in Chicago last month committed 
that with $500 million of Afghan government support for 
security forces, the international community would be 
contributing about $3.6 billion, for a total of $4.1 billion 
over the long term out through 2017 and beyond.
    That was coupled with a commitment on the part of 
Afghanistan that Afghanistan expected to be able to fund its 
own security forces by 2024. So we look at continuing large 
international contributions, but at a declining rate with a 
goal of Afghanistan being able to support its entire security 
establishment, including the military medical establishment, by 
2024.
    Mr. Brooks. So if my math is correct, roughly a dozen years 
from now is when the hope is that Afghanistan will be able to 
carry their own load?
    Mr. Sedney. That is the goal that the international 
community is working with Afghanistan to support. In a meeting 
a couple of days ago in Tokyo on economic development 
assistance, the countries of the world agreed to continue 
funding for Afghan development and economic assistance that 
supplements that commitment to security assistance that was 
made in Chicago by the NATO countries and the partners.
    So, yes, there will be a continuing very large need on the 
part of Afghanistan, but our allies have stepped forward to 
contribute even more. The relative weight of the United States 
contribution, if I can just give you some numbers, sir. In the 
current fiscal year, we will be spending about $11.2 billion to 
support the Afghan security forces.
    Our budget request for next year is $5.75 billion, a very 
large reduction. For the longer term, we are looking at that 
$4.1 billion, a larger portion of which, a significant portion 
of which has been committed to by other countries.
    So, yes, it is a large amount of money. But it is going to 
be decreasingly a burden on U.S. taxpayers, more and more 
shared by other countries. And eventually, yes, Afghanistan 
is--Afghanistan's goal is to be able to support itself, but it 
is a long time away.
    Mr. Brooks. Thank you, Mr. Chairman.
    Mr. Wittman. Thank you, Mr. Brooks. We appreciate your 
questions.
    And we will move now to Mr. Coffman.
    Mr. Coffman. Thank you, Mr. Chairman.
    Ambassador, let me start with you. So in your investigation 
of the problems at the hospital, you concluded that there were 
a lack of standards that were set in place, and that was part 
of the problem? Am I correct in that?
    Ambassador Moorefield. Yes, Congressman. I would agree with 
you that that was a very significant part of the problem 
because I think even part of the ethical issue that our medical 
mentoring personnel were having had to do with not knowing 
exactly what it was their role was supposed to accomplish in 
terms of mentoring their personnel. So it was very hard to see 
where the line was in terms of what they should be helping them 
do to accomplish.
    I think the introduction of standards is absolutely 
critical. It was something we identified at least 3 or 4 years 
ago. I think, as I recall, there was a visit by the Surgeons 
General of our Army, Air Force, Navy, and they also pointed out 
several years ago that without standards, how could you have a 
focused mentoring mission and how could you hope to possibly 
achieve an appropriate end-state objective?
    Mr. Coffman. And that was a function of training? Isn't 
that a part, the establishment of standards is a part of the 
training mission?
    Ambassador Moorefield. It is part of the NTM-A CSTC-A 
responsibility. Is that----
    Mr. Coffman. That is correct. And that was General 
Caldwell's responsibility, was it not?
    Ambassador Moorefield. Well, it was during the time that he 
was there. And of course, it was a responsibility that preceded 
him and succeeded him.
    Mr. Coffman. And I think, in my view, he displayed a 
fundamental lack of leadership in the performance of those 
duties, and there will be a further investigation of this. I 
think a hearing in 2 weeks in the Oversight and Government 
Reform Subcommittee that will go into much greater depth.
    And I have talked to some of his staff, or my office has 
talked to some of his staff. I have talked to one member of his 
staff directly, and my office has talked to another. And I 
think that the problem really rose to the top, in my view. And 
it is stunning that he is still serving today in the United 
States Army after all that has occurred here.
    Let me say that I think that, Mr. Sedney, your description 
of events is fairly sanitized. Is it not true that there were 
Afghan security forces dying in the hospital from suffering 
malnutrition, suffering from untreated wounds because, in fact, 
their families couldn't come up with the necessary bribes for 
the hospital personnel?
    Isn't that, in fact, true?
    Mr. Sedney. Representative Coffman, as I said in my 
statement, there was a wide range of abuses and problems in the 
National Military Hospital for a number of times. As we 
increased the number of our advisers there and as those abuses 
were brought to our attention, we began to take action to try 
and address them. And that action has been difficult because of 
the level of medical care, as Representative Cooper pointed out 
there.
    But also because of individual--because of problems with 
the way individuals were acting. Getting the change in the 
leadership in the hospital was essential and getting in place 
the standards that the ambassador mentioned. So where we are 
today is a great deal farther forward than we were 2 and 3 
years ago when the conditions that you described existed.
    I would say that the biggest problem that looking back at 
it is that when we began this effort, it was underfunded, 
underresourced. And it was only after we increased our number 
of advisers in the post 2009 period that we were able to take 
the effective action that we have. So the situation today is so 
much better than it was during the period you are describing.
    Mr. Coffman. Well, I should say how slow the command was to 
respond and how slow you were to respond to this issue as it 
filtered up in terms of talking to some of the people that were 
mentors on the ground. And at the point in time where they knew 
that there was a problem to the point in time that action was 
taken, there was a tremendous gap that doesn't, in my view, 
reflect a competence in leadership.
    With that, Mr. Chairman, I will yield back. Hope that there 
will be a second round.
    Mr. Wittman. Yes, Mr. Coffman, there will be. And I thank 
you for your questions.
    And we will move on now to Mr. Conaway.
    Mr. Conaway. Thank you, Mr. Chairman.
    Gentlemen, thanks for being here.
    Ambassador Moorefield, you used the phrase ``intervene'' a 
while ago in reference to what might be occurring in the future 
with things that would be going on there, either post 2014 or 
whatever. Does that represent a change in mission for our 
advisers that are there?
    Because, previously, when Mr. Cooper read the mission 
statement for our folks, it was to watch what they are doing, 
advise, but we don't do any clinical work. We don't change 
dressings. We don't do the things that I know that our folks 
who watched these bad things go on, which they are itching to 
do. Is that a different word for them today than what would 
have been in place during the time in question?
    Ambassador Moorefield. Thank you, Congressman Conaway.
    Our concept, our understanding of their concept of the 
command's goal here is to transition not just with respect to 
mentoring of the Afghan National Security Force's hospital 
system, but for the Afghan security forces as a whole, to their 
taking the lead.
    And when I say ``intervene,'' I meant that if they needed 
mentoring because it was clearly something their mission, their 
function, they were not fully prepared to carry out and it 
became evident, then we would intervene and provide that.
    Mr. Conaway. So if somebody in an operating room were 
starting to bleed out and we had a surgeon there watching and 
can save their life, he would have the authority to step in and 
help save that life?
    Ambassador Moorefield. I do not believe that their current 
mission includes directly intervening.
    Mr. Conaway. Okay. So the word ``intervene'' has a 
different definition?
    Ambassador Moorefield. Yes.
    Mr. Conaway. Leon got a letter. Panetta got a letter from 
Jay, from Chafetz and the committee that Michael was 
referencing to. Dr. Kem directed, I think, a Colonel Mark Fassl 
to send you an email October 28, 2010. And then, apparently, 
there was a bit of a dustup in Kabul with Caldwell and others, 
and they attempted to retract that.
    As Inspector General, does that give you a red flag that 
gives you a chance to wade in? Or given the fact that the 
three-star withdrew the request blocked you from being able to 
try to get at these issues a little quicker than might have 
otherwise happened under the actual timeframe that actually 
happened.
    In other words, how much time was lost by you getting your 
team in there to see for yourself what was going on?
    Ambassador Moorefield. Let me recall exactly what happened 
from our vantage point and my vantage point. Yes, I did receive 
an email from the CSTC-A IG, Colonel Fassl, whom I knew well, 
and had several phone conversations with him about the 
command's interest in having DOD IG provide a mission, an 
oversight mission.
    And this was, as you said, towards the end of October. What 
I told him at the time is we were absolutely committed to 
supporting that, and we would begin preparing to do so right 
away, which we did, because they were talking about a mission. 
He was talking about a mission that would have a very short 
fuse, given the normal lead time that CENTCOM [U.S. Central 
Command] and the command requires.
    So we were already well along when I finally received a 
letter, I think it was the 10th of November, from General 
Caldwell saying please come out and perform this logistical 
system oversight mission. So, in fact, I had a team on the 
ground the day after Thanksgiving, which, I have to say, given 
that I had to mobilize subject matter experts in addition to 
our own personnel was probably some sort of record response to 
any request we have ever received.
    Mr. Conaway. How long did it take you to get the work done? 
When did they finish up the field work, so to speak?
    Ambassador Moorefield. On that particular mission, the 
report was issued in May or June of the following year.
    Mr. Conaway. Again, we are operating through a lens of----
    Ambassador Moorefield. Yes, I was just going to say--excuse 
me for interrupting. But of course, they got a full outbriefing 
from our team before we left. So they knew what the issues were 
by the time our people left Afghanistan.
    Mr. Conaway. And based on what you know, since then did 
they actually take action ahead of your report in May, or did 
they let the conditions continue to----
    Ambassador Moorefield. They took action in a number of 
respects, but I should point out that there were two follow-up 
missions that we implemented. One was that February following 
that mission that came back just before Christmas in December 
of 2010.
    By February, we were on the ground inspecting the National 
Military Hospital in a very specific way.
    Mr. Conaway. How is that different from what you did in 
November and December?
    Ambassador Moorefield. Well, what we did in November and 
December was a countrywide review of the entire logistical 
system and whether or not it had accountability and controls 
over U.S.-supplied equipment and pharmaceuticals.
    Mr. Conaway. So patient mistreatment wasn't your focus 
until February?
    Ambassador Moorefield. It was not what was requested. And 
even though we took note of conditions, it wasn't until we got 
a specific report, in fact, our IG received a specific report 
in, I think, November of 2010 when he was on the ground in 
Kabul from the command, indicating that there were patient care 
issues at the hospital that we deployed the team very soon 
thereafter. I think almost a week from the time we found out 
about this mission, we had a team on the ground there 
inspecting the hospital.
    And then, in addition, we sent an audit team out to take a 
look at the pharmaceutical accountability and control 
countrywide and then specifically also at the NMH. So there 
were a succession of oversight missions that ensued during that 
period.
    Mr. Conaway. I am over my time. But you said a team that 
went to look for the patient mistreatment was November 2010 or 
November 2011?
    Ambassador Moorefield. If you are referring to the National 
Military Hospital, that was February 2011.
    Mr. Conaway. All right. That is the first time you had 
anybody looking at the patient mistreatment?
    Ambassador Moorefield. In detail, yes.
    Mr. Conaway. Okay.
    Thank you, Mr. Chairman.
    Mr. Wittman. Thank you, Mr. Conaway.
    We have been joined by Ms. Speier, who is a member of the 
full committee. And at this point, we will go to her, and then 
we will return to the subcommittee members for a second round 
of questioning.
    Ms. Speier.
    Ms. Speier. Thank you, Mr. Chairman and Ranking Member 
Cooper, for holding this important hearing.
    I am deeply troubled by the reports that we have heard, and 
I think this hearing underscores a very important question, 
which is, is the Department of Defense living up to its 
responsibilities to root out waste and fraud of taxpayer 
dollars?
    I would like to express disappointment, however, that 
Colonel Geller is not before the committee to discuss his 
concerns about the significant level of corruption in the 
Afghan military medical organization. If his allegations are 
true, we can only conclude that the Army was complicit in 
wasting millions of dollars and the horrendous neglect and 
abuse of patients that had a reasonable expectation of quality 
care.
    It is clear that a follow-up hearing on this issue is 
needed, and it is my hope that Colonel Geller will be the first 
to testify so that the facilitators of wrongdoing can respond 
to his concerns.
    With the chair and ranking member's permission, I would 
like to submit into the record a news article that lays out 
Colonel Geller's concerns.
    Mr. Wittman. Without objection.
    [The information referred to can be found in the Appendix 
on page 51.]
    Ms. Speier. Most troubling to me, however, is Major General 
Gary Patton's alleged role in covering up this corruption. 
According to press reports, he urged the suppression of an 
investigation into this wrongdoing by urging Lieutenant General 
Caldwell to defer an investigation until after the 2010 
congressional elections.
    It also appears that when he learned that an external 
review was not supported by his commander, he backed off of his 
recommendation for an external investigation of the wrongdoing.
    I have also learned that once the Pentagon Inspector 
General investigation was underway, Major General Patton may 
have attempted to obstruct the investigation by intimidating 
witnesses. Now those are very serious charges.
    As the newly appointed head of the Sexual Assault 
Prevention and Response Office, or SAPRO, Major General Patton 
will have primary responsibility for cases that are not 
politically popular, particularly by his senior commanders. I 
worry that instead of enforcing justice, he will only enforce 
what advances his career, making his interests almost 
diametrically opposed to getting justice for victims.
    These allegations imply that he has used his leadership to 
create a chilling effect against reporting wrongdoing, instead 
of facilitating the command environment necessary to maintain 
zero tolerance for these abuses.
    If any of these allegations are true, I have very serious 
concerns about Major General Patton's capacity to be an 
effective advocate for victims of rape in the military. I 
believe that it is this committee's duty to investigate the 
veracity of these claims and to take up the question of whether 
Major General Patton is the appropriate choice to head SAPRO.
    I look forward to working with my colleagues on this issue, 
and I yield back.
    Mr. Wittman. Thank you, Ms. Speier.
    We are going to begin a second round of questioning. And 
with that, I am going to go to Mr. Coffman.
    Mr. Coffman. Thank you, Mr. Chairman.
    What is stunning in this whole situation is the fact that 
we have U.S. taxpayer dollars flowing into Afghanistan, 
obviously, in addition to the contributions of our allies. But 
predominantly, U.S. tax dollars are funding much of the Afghan 
security forces, certainly to include the Afghan medical 
component of that. And that we have all these dollars flowing 
in, but yet a real lack of oversight over them.
    And as we draw down, obviously, we are going to have fewer, 
a lighter footprint there. And so, I am very concerned that, 
first of all, obviously, we haven't dealt with the situation 
that has occurred, I think. But we will in time, hopefully, 
whether both with General Yaftali on the Afghan side and 
General Caldwell on our side.
    But also I think the fact that we are going to have a 
lighter footprint, one of the concerns expressed was that we 
didn't have enough personnel to monitor the situation. And now 
how are we going to monitor it in the future?
    How are we going to make sure that we deal with this 
culture of corruption in terms of how U.S. tax dollars are 
handled prospectively? And I am real concerned about that.
    Mr. Sedney, why don't you try and address that?
    Mr. Sedney. Thank you, Congressman.
    You have raised some very important questions. I do want to 
just comment for the record that because there is an ongoing 
investigation regarding the individuals that were mentioned 
earlier that we are not allowed to comment on that. We, of 
course, have heard allegations, but once this ongoing 
investigation is completed, then we will be able to respond to 
some of the allegations and various stories that appear to have 
been in the press.
    The questions about the ability to account for U.S. 
taxpayers' dollars, to account for whether we have achieved the 
goals that we have set, as you mentioned, Representative 
Coffman, is very important.
    Certainly up until 2008, our advising effort in Afghanistan 
was underresourced and underfunded. This was recognized by this 
administration, and the surge into Afghanistan included a surge 
in advisers, mentors, and trainers, both from the United States 
and from our allies, that enabled us in a host of areas, 
including in the national military area, to put in place high-
quality mentors who had the ability to take a look behind the 
scenes what was happening.
    That is why we were able to discover the problems that you 
have laid out and why we were able to work with the Afghans to 
put in place systems that they just didn't have before for 
monitoring. In Ambassador Moorefield's testimony, he lays out 
some of the improvements that have begun to be made.
    Those improvements are ongoing. One of the major tasks that 
we have right now out in the field is to help the Afghans build 
those systems, work those systems, including the investigatory 
efforts that are going on that I mentioned earlier, and then to 
monitor to see if they are working.
    And then, this is where the intervention comes in, sir, we 
have to try and intervene on a policy way to try and get the 
policies and procedures that the Afghans are using up to the 
level so that we can get the level of certainty that we need.
    Mr. Coffman. Are we serious about this now? Because, 
obviously, we weren't serious about this in the past. But all 
of a sudden, now we are serious about the----
    Mr. Sedney. I would say that certainly since we have put 
more resources into this, we are very serious. It has not just 
the attention of the highest levels. It has the attention of 
the Department, but also of our leaders in the field.
    Mr. Coffman. Why weren't we serious in the past?
    Mr. Sedney. I don't say it wasn't serious. I say it was 
underfunded and underresourced before 2008.
    Mr. Coffman. You don't think there was a lack of leadership 
there?
    Mr. Sedney. I think before 2008, we just didn't have--
before 2008, we just didn't have the resources to follow 
through with doing it.
    Mr. Coffman. You don't think it was lack of leadership? 
That the fact that the leadership couldn't even tell that there 
was a, couldn't even say, ``Hey, I don't have enough resources 
here. Because we don't have the resources here, we have got 
some problems with corruption.''
    Or do you think the leadership just wasn't even paying 
attention because how could you miss something so big?
    Mr. Sedney. I think that the leadership on the ground 
before 2008, going back to 2004, 2005, 2006, and 2007, 
recognized that there were problems that they weren't able to 
address because they didn't have the resources and made the 
request for additional resources in terms of mentors and 
oversight ability. But we were not--we, the United States, were 
not in a position to provide the level of resources----
    Mr. Coffman. So what we did instead of that was we just 
allowed corruption to occur. We didn't care about accounting 
for U.S. taxpayer dollars. I guess that was okay then because 
we didn't have enough people there, and we just didn't know 
what was going on. Is that what you are trying to say?
    Mr. Sedney. No. I am saying that the people who were there, 
who tried very hard to do sometimes the jobs of two, three, 
four, and five people, were overwhelmed by the level--by the 
amount of the challenges and the amount of effort that they 
have in that period of 2004, 2005, 2006, 2007, and 2008.
    The situation, as Representative Cooper described it, it 
was very accurate in terms of the challenges that were faced. 
And so, we had a lot of good people doing their very best, but 
they were overwhelmed by the magnitude of the problems.
    Mr. Coffman. I think we disagree with this, and I think the 
truth will come out.
    Mr. Chairman, I yield back.
    Mr. Wittman. Thank you, Mr. Coffman.
    And we are going to go now to Mr. Cooper.
    Mr. Cooper. Thank you, Mr. Chairman.
    I am a little worried that with all this talk of standards 
for the Afghan healthcare system and monitoring and resources 
and all that good stuff, that sounds like we are talking about 
it in a nice, air-conditioned hearing room in Washington. And I 
am no expert on Afghanistan, but the reality on the ground, 
when they have intermittent hot water, intermittent 
electricity, all kinds of personnel and quality problems that 
we can't even imagine, that without enforcement, without some 
ability for U.S. personnel to step in and, as my colleague Mr. 
Conaway was saying, stop somebody from bleeding to death 
because the bribe wasn't big enough to save the life.
    Or to give a starving man a candy bar that might tide him 
over until the next day until the family can come up with the 
bribe money or whatever other nightmarish scenario is out there 
that without enforcement, we are still putting good U.S. 
personnel in an impossible situation.
    Like why do that? Because even being associated with this 
mess can ruin a career. And standards sound fine, and they 
sound good for us, but that just assumes that there is going to 
be some sort of accountability or enforcement or people want to 
do right.
    We are worried here about green on blue violence. Well, 
this is green on green violence, and it seems to be, sadly, a 
part of the culture. Well, maybe that is why they are the 
second-poorest country in the world.
    So I worry about good, clean U.S. personnel like it is the 
worst assignment in the world. So whoever is associated with it 
must have drawn the short straw to get this. I always thought 
that the Aleutian Islands was the worst posting you could get. 
This has got to be the worst of the worst.
    So I am not making excuses for any of this bad behavior, 
but to apply Western standards to this is like completely 
unrealistic. If our guys are just tasked with the job of 
standing there and looking at evil, looking at Afghan people 
destroying the lives of their own Afghan military, and 
presumably with Western aid or even minimal local resources 
they could have done something about that, at least let their 
own family members nurse the poor invalid.
    So standards, monitoring ain't going to do it. It is going 
to take some sort of ability to intervene or enforce or do 
something. Otherwise, we are putting our folks in a bad place.
    Would anyone like to comment on that?
    General Robb. Yes, sir. The feedback we are getting from 
the surgeon over there for the National Training Mission-
Afghanistan, as was also evidenced by the IG report, is 
subsequent to three major events that occurred in the fall of 
2010. One was increased mentors on the ground. And the early 
fall, mid fall was, of course, when they transferred the 
medical logistics from the National Military Hospital system to 
the ANSF Logistical Command.
    And then, but more importantly, late fall/early winter was 
the subsequent relief of about 25 senior medical leaders. And I 
think that was the key to include, as you know, their surgeon 
general and also dual-hatted as the hospital commander.
    So fast forward 1 year plus about 6 months later, you get a 
report, again as recent as June 2012, that addresses many of 
those issues, sir, that rightly we have concerns and you have 
concerns. So the key that has happened, and again in direct 
discussions with the leadership on the ground, the mentors, is 
that the approach that they have taken is you have heard that 
they have standards now.
    In other words, we are not using Mayo Clinic standards. We 
are using the standards that are appropriate for the level of 
care that would be delivered in Afghanistan. We are using what 
we call the Tier 1 or the cure standards. So now they have a 
definitive end-state of which they know that they must 
accomplish.
    And so, what the new leadership, again expressly through 
the leadership of the new hospital commander there, he 
personally takes interest in any cases of abuse, of which there 
have been none reported, you know, in the recent 6 months. And 
the way they did that was because of a leadership change.
    So what our mentors did was when they saw during last year, 
as they were cultivating a culture of accountability in the new 
leadership, they got those to chief nurse, the chief of 
surgery, and the hospital commander also demanded to be 
involved in those cases of suspected either undertreatment or 
maltreatment. And so, they were involved.
    And so, that is why you see now, with accountability 
through their leadership, there is no shortage of people that 
want to do good things in Afghanistan, and I have experienced 
that. You know, they are underresourced, okay, and they may be 
undereducated, but there is no shortage of, again, good people 
with the desire to do the right thing over there.
    And I have been impressed with the Afghan, again, medical 
professionals. That doesn't mean there weren't bad actors over 
there, but I have met many of them that are good.
    So I am encouraged, sir, again. And it is going to take 
time. And that leadership, that culture change began, again, 
with what I would call weeding out of the 25 poor leaders and 
have been replaced with leaders that our mentors now and our 
medical leadership over the training mission believe they have 
the right stuff to help turn the tide there not only in the 
National Military Hospital, but also within the whole Afghan 
healthcare system.
    As was mentioned before by my colleagues here, there are a 
lot of success stories out there. I mean, when you look at 
Kandahar, you look at Herat, Mazar-e-Sharif, Gardez, these are 
the regional hospitals that we share with the Ministry of 
Public Health. And they are, again, by Afghan capability, 
standards, training, and by the resourcing, they are doing an 
incredible job.
    And quite frankly, I am proud of them. I am proud of them, 
again considering where they have started. Four decades of 
really neglect because they weren't allowed to, again, train to 
what was appropriate for Afghan standards because of four 
decades of war and, again, back and forth with the different 
folks that have occupied their country.
    So I am encouraged by the direction that has taken place in 
this last year.
    Thank you very much.
    Mr. Wittman. Thank you, Mr. Cooper.
    We are going to go to Mr. Conaway.
    Mr. Conaway. Just real quickly, this may sound pretty 
frivolous, but in terms of where they are right now, do they--
Mr. Sedney or General Robb, do our advisers run customer 
satisfaction surveys of folks coming out of the hospital to see 
if there are lingering or ongoing issues that aren't obvious, 
or do you actually use that tool? Or does it make sense to use 
that tool in that society?
    General Robb. Sir, I will have to get back to you on that. 
I am not sure. I know that we have validation teams that are 
going through now to match against the standards. And then 
Ambassador Moorefield may have more detail on that.
    Ambassador Moorefield. Yes, thank you.
    They do. They do run customer surveys. And our team, while 
they were there, by the way, inspecting the hospital, spoke 
with many patients. They have a bill of rights. It was not well 
understood and shared with the patients previously.
    It is now explained to them when they enter the hospital. 
And when we discussed what their rights were with the patients, 
they knew what their fundamental rights were, to get three 
square meals a day, to have a doctor see them every day and a 
nurse every 8 hours. So I would say that there is certainly an 
enhanced consciousness about the obligations of the hospital to 
the patients and the patients' understanding of those 
obligations.
    Mr. Conaway. The customer satisfaction surveys that we run, 
are they controlled in a way that the folks who are being 
evaluated don't have the ability to skew the results?
    Ambassador Moorefield. As part of the standard that is 
applied now, they have to conduct regular customer satisfaction 
surveys and put it in writing.
    Mr. Conaway. The Afghans do?
    Ambassador Moorefield. So we are not aware that they are 
anything but objective.
    Mr. Conaway. Best you can tell.
    Ambassador Moorefield. But we will--we are going to 
continue to provide oversight. So that is one of the things we 
will be looking for.
    Mr. Conaway. In the agreement that was made for the $4.1 
billion, Mr. Sedney, does it have enough teeth in it to allow 
the proper oversight of these functions as the dollars flow, 
continue to flow to the system during those timeframes?
    Mr. Sedney. Yes. We have some very good accounting systems 
that we are putting in place. And the continuation of the 
funding obviously will be based on the Afghan military and 
police's performance. But they are going to be tested this 
year, as I have mentioned before.
    Mr. Conaway. Thank you, Mr. Chairman.
    Mr. Wittman. Thank you, Mr. Conaway.
    We will now go to Ms. Speier.
    Ms. Speier. Thank you, Mr. Chairman.
    I just have one question for Major General Robb. You 
indicated that there is a change of leadership there, and over 
the last 6 months, things look like they are much better.
    Who would someone report a problem to in the existing 
system if there was denial of care or denial of service? Who 
would they report that to, and how would they be informed of 
that as a patient?
    [Pause.]
    General Robb. Yes, ma'am. As I stated before, the 
leadership--and again, as have been pointed out to us, 
specifically, the chief of surgery, the chief nurse, and also 
the hospital commander have taken this personally under their 
role to, again, address each one of these cases where folks 
feel that they were either underserved or not treated properly. 
The first directors of the hospital have also been instructed 
that if they discover something to pass that up again to the 
senior leadership for them to personally address that.
    Ms. Speier. But if I am a patient there----
    General Robb. Yes.
    Ms. Speier [continuing]. And I am seeking care and I am 
told, ``Well, unless you give me $10,000, I am not going to 
give you care,'' how would I know who to report that to? When 
they walk in, are they given some patient bill of rights to say 
at no point should you be subject to any kind of bribe? 
Healthcare here is provided without additional remuneration 
or----
    General Robb. Yes, ma'am. That is part of the bill of 
rights. That is what they are instructed on when they are 
actually admitted to the hospital.
    Ms. Speier. Would you make a copy of that bill of rights 
available to the committee?
    General Robb. Yes, ma'am. Yes, ma'am.
    Ms. Speier. Thank you. I yield back.
    [The information referred to can be found in the Appendix 
on page 58.]
    Mr. Wittman. Thank you, Ms. Speier.
    We will now go to Mr. Coffman.
    Mr. Coffman. Thank you, Mr. Chairman.
    Let us talk about, going forward now, that here is my 
concern that not only going to be reducing our footprint, but 
as we get to 2014, to the end of 2014 when we are expected to 
give operational control or switch operational control to 
Afghan security forces. And at that point in time, our 
expectation is that they will have the internal capability, 
logistically, administratively, to take U.S. military aid in 
whatever form, U.S. military medical aid and other forms, and 
to be able to disseminate it to their subordinate commands.
    That actually increases the potential for corruption. So 
how are we going to be able to monitor that going forward?
    Mr. Sedney. The procedures for monitoring--for the Afghans 
to be able to monitor, first of all, that they have to build up 
their own ability to have an inspector general capability, 
which NTM-A is working on to build, so that they can 
investigate problems and issues and come up with ways both to 
fix problems and also to recommend problems to the law 
enforcement bodies is a capability we are developing.
    That capability is one that we are only more recently 
starting to work on because the original part of building the 
Afghan security forces was focused on the fighting forces. 
Building the supporting structure, such as you are describing, 
is what we are doing now.
    We are going to have to examine that progress as we go 
along, and that will go into the determination of what kind and 
level of presence we need after 2014 either from the United 
States or from our coalition allies as we continue that train, 
advise, and assist mission after 2014.
    But really, it is going to depend upon the performance of 
the Afghans themselves and the determination of the commander 
in the field as to what is necessary. It is a great question, 
and we don't really have the full answer yet, but we will be 
developing it over the next 12 to 24 months.
    Mr. Coffman. Ambassador Moorefield, do you have anything?
    Ambassador Moorefield. Yes, sir. I think that one of the 
commitments that we have made in this post 2014 through 2024 
era in terms of the continuing development of the Afghan 
National Security Forces is their logistical system. And 
essentially, aside from getting bullets and food and medical 
care to the troops in the field or the police forces wherever 
they may be deployed, there has been a very serious ongoing 
effort, and this will continue post 2014 to build up their 
logistical capability, to provide accountability and control 
for their resources because we will be providing fewer 
resources. They will be paying for more of the resources. So 
this isn't just about taking care of congressional and U.S. 
taxpayer and other coalition-supported resources.
    So building those accountability and control mechanisms is 
a top priority. I would mention one of the reasons why I think 
I personally believe this is going to be an ongoing 
responsibility and challenge is building a logistical system is 
a lot more complex than turning out fighting forces or 
policemen on the beat.
    And it is the case that we prioritize creating their--
generating their security forces and only in the last few years 
have put our shoulder to the wheel on building up their 
logistical system. But it is complex challenges, and it is 
going to be an ongoing assistance effort.
    Mr. Coffman. Well, thank you, Ambassador, Mr. Sedney, 
General. I hope we don't learn that the hard way, as we have 
obviously seemed to be learning things in Afghanistan up to 
this point.
    Mr. Chairman, I yield back.
    Mr. Wittman. Thank you, Mr. Coffman.
    We will now go to Mr. Cooper.
    Mr. Cooper. Thank you, Mr. Chairman.
    I don't want to prolong this unduly, but it is my 
understanding that the life expectancy in Afghanistan is among 
the shortest in the world. And an adult male lives to maybe his 
late 40s, something like that?
    So just allowing them to revert to the previous standard is 
half the life that a U.S. citizen would expect to live. I don't 
know what it would be if you were denied the state-of-the-art 
U.S. battlefield medicine. That would have to increase your 
chance of death from a bullet wound, from 1 percent to 50 
percent, 70 percent, something like that.
    So, again, in my opinion, it is very difficult for us to 
even understand a Fourth World medical system, and I hope we 
don't continue to put good U.S. folks in jeopardy by putting 
them in an impossible management situation.
    Thank you, Mr. Chairman.
    Mr. Wittman. Thank you, Mr. Cooper. We appreciate that.
    Are there any other questions of the committee members?
    Panelists, we thank you so much for joining us today. We 
appreciate you giving us your perspective on the challenges 
that we face there in Afghanistan. This is one of many, 
obviously, the medical system there itself and the efforts of 
providing care to the Afghans, as well as the issues of 
corruption there, things that are very much at the foremost of 
folks' minds here on the committee. So we appreciate you 
shedding some light on that.
    We did have a few requests for some information. We would 
appreciate it if you would be timely in getting that back to 
the committee for our consideration.
    And I want to remind committee members, too, if you have 
any additional questions, please let us submit those in writing 
to the panel members.
    And if there is no further questions, we appreciate the 
panelists' time, and this hearing is adjourned.
    [Whereupon, at 4:23 p.m., the subcommittee was adjourned.]
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              WITNESS RESPONSES TO QUESTIONS ASKED DURING

                              THE HEARING

                             July 10, 2012

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              RESPONSE TO QUESTION SUBMITTED BY MR. YOUNG

    Mr. Sedney. Response to Information Request for Quarterly 
Assessment Reports of Dawood by NTM-A/CSTC-A Validation Team for NTM-A/
CSTC-A Surgeon's Office (CJSURG) assessing all ANA hospitals on a 
quarterly basis, using their Healthcare Standards tool.
    Quarterly Assessment Summary: The Afghan National Military Hospital 
(NMH) is evaluated utilizing a healthcare standards tool to validate 
Capability Milestones (CM). The goal is for the NMH to operate 
autonomously. The NMH displayed significant improvement and received a 
CM1B rating during its May 2012 assessment, up from a CM2A rating, 
received during the February 2012 Quarterly Assessment.
    The NMH demonstrated best practices (CM1A) for Blood Bank, Central 
Sterile Service Department (CSSD), Dental, Human Resources, Intensive 
Care Unit (ICU), Internal Medicine, Laboratory, Leadership Council, 
Medical Logistics (MEDLOG), Nursing, Operating Theater, Outpatient 
Clinic, Patient Administration, Pharmacy, and Surgery. The Biomedical 
Repair, Facilities Management, Infection Prevention, Radiology, and 
Ultrasound departments earned CM1B ratings.
    The remaining departments are at a CM2A rating, which NATO Training 
Mission-Afghanistan (NTMA-A) expects will improve with enhanced 
mentoring, training, well-written standard operating procedures (SOPs), 
and improved organizational structure. Emergency and Anesthesia have 
been identified as functional areas requiring improved leadership. The 
Emergency Department also requires improved written SOPs, improved 
equipment/supply organization, more attention to cleanliness, 
renovation, and space expansion. The Anesthesia Department requires 
greater supervision and oversight, equipment management, and clerical 
documentation.
    The ANA Medical Command (MEDCOM) has established an Afghan 
validation team that allows for direct reporting of hospital elements 
and practices to the ANA Surgeon General. Through the ANA MEDCOM 
validation team, the NMH should realize significant gains in its health 
system. This process will be completely led by ANA leadership. [See 
page 12.]
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              RESPONSE TO QUESTION SUBMITTED BY MS. SPEIER
    General Robb. [The chart provided can be found on the following 
page.]    [See page 23.]

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              QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                             July 10, 2012

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                   QUESTIONS SUBMITTED BY MR. COOPER

    Mr. Cooper. Please describe in detail the ``vast improvements'' 
made in the accountability of hospital leadership and staff, general 
sanitation of facilities, the standard of patient care, and the 
supporting logistics systems.
    Mr. Sedney. Afghanistan's National Military Hospital (NMH) has made 
improvements in the accountability and responsibility of its 
leadership. Demand for training and education at the hospital has also 
increased. The combination of these changes will result in improved and 
sustained patient care.
    Improvements in NMH leadership and staff accountability, general 
sanitation standards, standard of patient care, and logistics systems 
are underway. Following the removal of General Ahmed Zia Yaftali as 
hospital commander, new leadership established more stringent planning 
and oversight to advance the professional conduct and accountability of 
the Afghan National Army (ANA) medical staff, with special attention 
towards combating staff absenteeism. Major General (MG) Wardak, ANA 
Surgeon General, established rules, regulations, and policies that 
Brigadier General (BG) Sherzai, the NMH Hospital Commander, actively 
enforces. Since MG Wardak's appointment in February 2012, twice-daily 
attendance verification for all ANA NMH staff members has decreased 
absenteeism. Absence, depending on frequency and length, has resulted 
in pay deduction, transfers, or termination. Attendance verification is 
ANA-led and sustainable.
    Accountability for the general cleanliness of and sanitation for 
the NMH is a routine discussion topic with the Hospital Leadership 
Council (HLC). Hospital administration, facilities management, and 
nursing staff personnel monitor each floor for cleanliness. Having 
facilities sanitation and cleanliness as a routine HLC agenda item 
brings heightened awareness to all NMH leaders, as well as to the 
hospital commander. In 2011, the NATO Training Mission-Afghanistan 
(NTM-A) Medical Training Advisory Group (MTAG) mentors reported that 
the new hospital commander, chief of surgery, and chief nurse 
intervened in every case of alleged patient neglect; by August 2011, 
there were no substantiated cases of patient neglect. An ANA Nutrition 
Task Force was created, which implemented processes and monitoring 
systems to improve patient nutrition. MTAG mentors currently supply 
liquid supplements from the United States, but are working to develop 
an Afghan-led solution that is sustainable after 2014. The transfer of 
medical logistics from the ANA Surgeon General to the ANA Logistics 
Command (LOGCOM) allowed the Ministry of Defense to enforce standard 
controls over receipt, storage, accountability, and distribution of 
pharmaceuticals and other supplies. Newly implemented ANA medical 
inventory and tracking systems have brought greater transparency and 
efficiency to the supply chain management.
    Mr. Cooper. What remains to be done with improving accountability 
in the Afghan National Military Hospital?
    Mr. Sedney. Overall, accountability in the Afghan National Military 
Hospital (NMH) has improved greatly. Continued NATO Training Mission-
Afghanistan (NTM-A) mentorship will sustain the improvements in 
accountability.
    MG Wardak, ANA Surgeon General, established rules, regulations, and 
policies that BG Sherzai, NMH Hospital Commander, actively enforces. 
Since MG Wardak's appointment in February, twice-daily attendance 
verification for all Afghan National Army (ANA) NMH staff members has 
decreased absenteeism. Absence, depending on frequency and amount of 
time, has resulted in pay deduction, transfers, or termination. 
Attendance verification is ANA-led and sustainable. Personnel 
accountability is further tracked through a Surgeon General-chaired 
meeting, held twice each week, where the hospital commanders provide 
daily reports on personnel accountability.
    MG Wardak has placed logistics, supply, and equipment 
accountability as a top priority. He has fined the Director of the 
Outpatient Clinic for allowing pharmaceuticals to expire and has warned 
BG Sherzai not to allow this waste to occur anywhere in the NMH. 
Logistical practices have been implemented to ensure that 
pharmaceuticals are rotated and not filled with items near expiration. 
The logistics system continues to advance with greater scrutiny on 
administrative oversight, personnel training, and maintenance of 
authorized pharmaceuticals. Accountability is further tracked through a 
Surgeon General-chaired weekly meeting that includes the ANA Logistics 
Command (LOGCOM) Commander, who provides an account on medical 
logistics.
    NTM-A Medical Training Advisory Group (MTAG) mentors will continue 
to advise ANSF medical leadership on the importance of continued 
enforcement of personnel and logistics accountability, as well as the 
importance of developing clear and concise standard operating 
procedures (SOPs). Moreover, ANSF-developed training programs need to 
be standardized and verified by Ministry of Defense (MoD), Ministry of 
Interior (MoI), Ministry of Public Health (MoPH), and NTM-A Medical 
Validation teams.
    Mr. Cooper. Will the U.S. Medical Training Advisory Group continue 
after the transition in Afghanistan? In what way?
    Mr. Sedney. We are currently assessing all of our post-2014 train, 
advise, and assist missions. Even though the Afghan National Security 
Forces (ANSF) Health Care System is well on the way to autonomous 
operations, we currently envision that the role of the Medical Training 
Advisory Group (MTAG) will continue, in a limited role, after 2014 by:
      Assisting the ANSF Health Care System leadership to 
conduct self-assessment of internal processes to identify areas of 
improvement via surveys, data analysis, and evidence-based best 
practices. Following validation of Regional Military Hospital (RMH) 
Herat, Afghan National Army Medical Command (ANA MEDCOM) and MTAG 
mentors will develop and implement a survey process that continues to 
improve the ANSF health care delivery;
      Encouraging ANA MEDCOM in the continued evolution and 
quality management of health care in Afghanistan to meet the changing 
challenges, needs, and wants of the ANSF;
      Mentoring greater cooperative health care efforts amongst 
the Ministry of Defense, Ministry of the Interior, and Ministry of 
Public Health.
    Mr. Cooper. Is the Afghan government committed to improving the 
ANSF healthcare system? If so, how and what actions have they taken and 
demonstrated to show this to the U.S. government?
    Mr. Sedney. The Afghan government has taken actions to improve the 
healthcare system in the areas of fighting corruption and in 
collaboration, capability, and accountability.
    Corruption--Since January 2012, under the direction of President 
Karzai, Afghanistan's High Office for Oversight and Anti-Corruption 
(HOOAC) assessed crimes committed at National Military Hospital (NMH) 
by both staff members and the former Surgeon General (Yaftali). As of 
July 2012, the HOOAC's efforts had led to seven potential cases for 
investigation and prosecution. Three cases were referred to the 
Ministry of Defense (MoD) Legal Department for investigation and 
prosecution. Two of these cases were referred to military courts. The 
four remaining cases (including the case against Yaftali) have yet to 
be referred by the HOOAC.
    Collaboration--In July 2012, Afghan National Security Forces (ANSF) 
hosted a two-day Healthcare Shura attended by medical leaders from the 
Afghan National Army (ANA), including the ANA Surgeon General, Minister 
of Defense (Health Affairs), and NMH and Regional Hospital Commanders; 
the Afghan National Police (ANP), including the ANP Surgeon General and 
Hospital Commanders; and the Ministry of Public Health (MoPH). U.S. 
Department of Defense Inspector General representatives also attended 
this event.
    The participants in the Shura discussed the current state of the 
ANSF healthcare system, the impact and challenges the ANSF faces as 
Coalition forces complete transition in 2014, and actions required to 
mitigate the impact of transition while enhancing Afghan stewardship of 
the ANSF healthcare system. A constant theme emphasized by ISAF leaders 
was that the responsible Afghan government entities must develop their 
own plan for taking ownership of ANSF healthcare, and that coordination 
and cooperation across the MoD, the MoPH, and the Ministry of Interior 
is critical throughout this process.
    Capability--The NMH demonstrated progress ahead of expectations in 
meeting quality performance criteria for the first tier capability of 
the ANSF Healthcare Standards, a key indicator of the NMH's readiness 
to transition. Furthermore, an Afghan-led team (ANA Medical Command) 
validated this effort with NATO Training Mission-Afghanistan (NTM-A) 
oversight.
    Accountability--Under the command of MG Wardak, the NMH has 
implemented improved procedures to ensure its medical personnel act in 
a professional and ethical manner and work their assigned hours. This 
accountability is monitored at the command level, with NTM-A mentor 
oversight, and verified in the Capability Milestone validation process. 
NTM-A plans to continue its oversight of NMH progress and the continued 
development of the Afghan healthcare system, which will be a key focus 
of the 2013 assessment process.
    Mr. Cooper. Does the U.S. government now have a way to account for 
pharmaceuticals supplied to the Afghan government?
    Mr. Sedney. Newly implemented medical inventory and tracking 
systems have introduced greater transparency and efficiency into 
pharmaceutical supply chain management.
    The transfer of medical logistics from the Surgeon General to the 
Afghan National Army's Logistics Command (ANA LOGCOM) allowed the 
Ministry of Defense (MoD) to enforce standard controls over receipt, 
storage, accountability, and distribution of pharmaceuticals and other 
supplies. These controls are embodied in Decree 4.0, described below.
    Decree 4.0 addresses logistics within the Afghan National Army 
system and specifically delineates logistics processing. The guidance 
states:
    All incoming supplies, including pharmaceuticals, are accounted for 
via MoD Form 8. This form is the receipt document for orders. A 
delegation of three members representing the ANA LOGCOM, Medical 
Command (MEDCOM), and Acquisition, Technology, and Logistics (ATL) 
initiates an MoD Form 8. The form details the number of supplies 
ordered, who shipped the supplies, and identifies any systemic 
deficiencies. A copy of the MoD Form 8 is sent to the following:
      Materials Management Division. A copy of the MoD Form 8 
is sent to the Minister of Finance and the Coalition comptroller, who 
validate receipts, orders, and funding allocated.
      Warehouse Manager. The Manager creates an MoD Form 1 to 
annotate that purchased materials have been added to the warehouse 
inventory.
    The processes above are monitored by Coalition mentors resident in 
the Medical Training Advisory Groups (MTAGs). The Coalition Comptroller 
validates receipts, orders, and funding for pharmaceuticals and other 
supplies. The MTAGs verify if hospitals have the pharmaceuticals and 
other supplies on hand, while Coalition logistics mentors verify the 
medical inventory in the warehouses.
    Mr. Cooper. What remains to be done with improving accountability 
in the Afghan National Military Hospital?
    Ambassador Moorefield. The ANA Medical Command (MEDCOM) is now 
under the command of Major General Mussa Warkak who has established 
responsible expectations for the conduct and performance of ANA medical 
personnel. Specifically, the National Military Hospital (NMH) has 
implemented procedures to ensure their personnel act in a professional 
and ethical manner and work their assigned hours. These procedures are 
positively impacting on NMH personnel accountable performance.
    Additionally, MEDCOM and NMH are taking action based on 
recommendations made in the DOD IG report ``Additional Guidance and 
Training Needed to Improve Afghan National Army Pharmaceutical 
Distribution'' Report No. DODIG-2012-083, published May 7, 2012. This 
report recommended that the ANA and MEDCOM develop a training program 
and implementation guidance specific to the pharmaceutical distribution 
process and the proper use of the Ministry of Defense (MoD) Decree 4.0 
logistics forms to properly receive, account for, and distribute 
pharmaceuticals. Additionally, it was recommended that MEDCOM undertake 
the same initiatives for non-Ministry of Defense forms addressed in 
Decree 4.0 that are used to collect and report pharmaceutical usage 
data. Pharmaceutical usage data is necessary to properly identify 
pharmaceutical resupply requirements for procurement. Furthermore, 
continued refinement and use of pharmaceutical usage data will help to 
prevent mismanagement, theft and waste of U.S. funded pharmaceuticals.
    Continued oversight by NMH, MEDCOM, ANA GS Inspectors General, as 
well as NTM-A and the DOD IG, is required to ensure that effective 
internal control procedures are in place and implemented to ensure the 
accountability of commands and their personnel with respect to medical 
supplies. Additionally, a collaborative relationship and effective 
communication between ANA Logistics Command and MEDCOM is critical to 
ensuring continued improvement of pharmaceuticals accountability and 
control throughout ANA, MEDCOM and at NMH specifically.
    Mr. Cooper. Will the U.S. Medical Training Advisory Group continue 
after the transition in Afghanistan? In what way?
    Ambassador Moorefield. Based on our discussions with NTM-A 
leadership and our assessment of the National Military Hospital 
(conducted from 28 June-5 July), we understand that both NTM-A and ANA 
medical leadership believe it is important to continue the medical 
advisory mission beyond 2014. Accordingly, we will request a plan which 
describes the medical advisory effort beyond the transition to Afghan-
lead of the National Military Hospital, which is estimated for the 3rd 
quarter of Calendar Year 2013, and then in the post-2014 transition 
era.
    Mr. Cooper. Is the Afghan government committed to improving the 
ANSF healthcare system? If so, how and what actions have they taken and 
demonstrated to show this to the U.S. government?
    Ambassador Moorefield. We have observed and reported on progress in 
the capability and performance of the ANSF healthcare system over time 
and believe this is an indication of the Ministry of Defense and ANA 
General Staff's commitment to continued reform and improvements. 
Specifically, ISAF continues to mentor the MoD/ANA and MoI/ANP to work 
together to further develop and improve the ANSF healthcare system. 
ISAF's efforts to improve ANSF healthcare also includes a collaborate 
effort with both the Ministry of Public Health (MoPH) and Ministry of 
Education (MoE). For example, in July 2012, ISAF together with the ANSF 
hosted a 2 day ANSF Healthcare Shura attended by medical leaders from 
the ANA (including ANA Surgeon General, MoD Health Affairs and NMH and 
Regional Hospital Commanders), ANP (ANP Surgeon General and ANP 
Hospital Commanders) and MoPH. DOD IG representatives attended this 
event.
    The purpose of the Shura was to discuss the current state of the 
ANSF healthcare system, the impact and challenges the ANSF faces as 
Coalition forces transition in 2014 and to initiate action to mitigate 
the impact of transition while enhancing Afghan stewardship of the ANSF 
healthcare system. A constant theme emphasized by ISAF leaders was that 
the responsible Afghan government entities must develop their own plan 
for taking ownership of ANSF healthcare from Coalition Forces and that 
coordination and cooperation across MoD/MoI/MoPH is critical throughout 
this process.
    We have observed additional indicators of Afghanistan's commitment 
to improving their healthcare system at NMH during our recent 
assessment. Specifically, NMH demonstrated progress in meeting the 
performance criteria to qualify for the first tier capability of the 
ANSF Healthcare Standards, a key indicator of their readiness to 
transition. Furthermore, it was an Afghan-led team who worked shoulder-
to-shoulder with NTM-A's validation team in determining this level of 
effort.
    We plan to continue our oversight of the NMH and the continued 
development of the Afghan healthcare system will be a focus of a future 
assessment planned for 2013.
    Mr. Cooper. Does the U.S. government now have a way to account for 
pharmaceuticals supplied to the Afghan government?
    Ambassador Moorefield. Under the new Afghan pharmaceutical 
distribution system developed by CSTC-A, U.S. officials provide funding 
and Afghan Acquisition, Technology and Logistics (AT&L) officials 
procure pharmaceuticals. The pharmaceuticals ordered should be based on 
requirements identified by Afghan Medical Command officials. The USG 
have both the CSTC-A Medical Training Advisory Group and Logistics 
Training Advisory Group providing guidance to these Afghan entities. 
During our audit, CSTC-A personnel were able to obtain and provide 
documentation of the items Afghan AT&L officials procured as well as 
documentation with the total funds spent to acquire the items. 
According to CSTC-A personnel, the USG is still responsible for 
managing vaccines for the Afghans separately from other pharmaceuticals 
because they require cold storage and transportation costs are higher 
and easily diverted.
    Mr. Cooper. Please describe in detail who the DOD IG team met with 
during the recent visit to Afghanistan.
    Ambassador Moorefield.
ISAF

Grp Cpt Steven Kilbey, UK, Deputy ISAF Surgeon

IJC

BG Norvell Van Coots, Surgeon General for USFOR-A, Medical Advisor to 
    COMIJC

NTM-A/CSTC-A

LTG Dan Bolger, USA, Commander NTM-A/CSTC-A
Cdre Mike Farrage, UK, Chief of Staff, NTM-A/CSTC-A
COL Kenneth Deal, USA, DCG-OPS, NTM-A/CSTC-A
COL Debra Daniels, USA, Director Content Management/Audit Oversight 
    NTM-A/CSTC-A
CAPT John Lamberton, USN, Chief of Staff CJSURG, NTM-A/CSTC-A
CAPT Fernando Moreno, USN, Deputy Command Surgeon, NTM-A/CSTC-A
CAPT Donald Worm, USN, Team Lead for Validation, NTM-A/CSTC-A
CDR Kathryn Mangion, USN, ANA Command Surgeon/Medical Command (MEDCOM) 
    Advisor, NTM-A/CSTC-A
CDR Joe Taylor, USN, MTAG Team Lead, NTM-A/CSTC-A
CDR Ethan Josiah, USN, MTAG Deputy Team Lead, NTM-A/CSTC-A
CDR Melissa Smith, USN, MTAG Nurse Advisor, NTM-A/CSTC-A
LCDR Steven Bailey, USN, MTAG Hospital Administrator Advisor, NTM-A/
    CSTC-A
LCDR Kelly, USN, MTAG Pharmacy Advisor, NTM-A/CSTC-A
Capt Sarah Byron-Smith, USAF, MTAG MEDLOG Advisor, NTM-A/CSTC-A
MSgt Troy Inabinet, USAF, MTAG Physical Therapy Advisor, NTM-A/CSTC-A
Ibanez Cocrates, MTAG Radiology Advisor, NTM-A/CSTC-A
HM2 Joanna Castro, USN, MTAG Dental Advisor, NTM-A/CSTC-A
LT David Varney, USN, MTAG Facilities/Administrator Advisor, NTM-A/
    CSTC-A
Dr. Susanna Cooper, MTAG Physician Advisor, NTM-A/CSTC-A
LCDR Gail Alexander, USN, MTAG Nurse Advisor, NTM-A/CSTC-A
Capt Kimberly Price, USAF, MTAG Nurse Advisor, NTM-A/CSTC-A
SSG Michael Lonak, USAF, MTAG Medical Logistics Advisor, NTM-A/CSTC-A
HM1 Alvaro Benitez, USN, MTAG Bio-Medical Repair Advisor, NTM-A/CSTC-A

ANA Medical Command

MG Mussa Wardak, ANA Surgeon General

ANA National Military Hospital (NMH)

BG Nazir Shirzai, ANA, NMH Commander
COL Jurhat, ANA, Chief of Administration
COL Hasan, ANA, Chief Pharmacist
COL Noorzai, ANA, Chief of the Medical Staff
COL Rahmani, ANA, Director of Medical Logistics
LtCol Latif, ANA, Chief Nurse
MAJ Ahmar, ANA, Plans Officer
MAJ Zia, ANA, Chief Quartermaster Pharmacy
MAJ Khalil, ANA, NMH Warehouse Manager
Lt Behroz, ANA, NMH Pharmacy Dispensary
Various Charge Nurses, Physicians and Patients at the NMH

    Mr. Cooper. Describe the joint effort between ISAF and the Afghan 
government to develop and implement an overarching ANSF healthcare 
system plan.
    Ambassador Moorefield. ISAF released the ANSF Healthcare System 
Development Support Plan to the COMISAF OPLAN 38302 in December 2011. 
This plan identifies the focus areas for the plan which are defined as 
follows:
    a) ANSF Medical System Organization--The organization of the ANS 
medical system will be optimized in terms of core processes, 
sustainable Tashkil \1\, clear and reliable command and control (C2), 
and capability laydown, thereby ensuring maximal efficiency of health 
care delivery.
---------------------------------------------------------------------------
    \1\ The Tashkil describes the authorized strength and structure of 
an ANSF organization.
---------------------------------------------------------------------------
    b) Personnel--Effective operation of an ANSF-developed, 
requirements-driven, personnel management system that continuously 
adapts to meet the changing needs of the Afghan Health system and 
results in optimal staffing, with appropriate geographic distribution.
    c) Education and Training--A standards-based, ethics driven system 
of education and training that produces professional and competent 
healthcare providers, administrators, and technicians that is 
responsive to enterprise requirements, adaptive to emerging demands, 
and sustainable.
    d) Evacuation--An efficient, sustainable ANSF ground casualty 
evacuation capability, tailored to geographical region, with developing 
en route care capability.
    e) Quality Management--An enduring culture of quality will exist 
within the ANSF health systems, manifest by continuously improving 
metrics of clinical outcomes, independently fostered by ANSF quality 
management experts and programs. Ideally, the ANSF culture of quality 
will spur development of and be supported by a culture of quality 
within the broader government health systems within Afghanistan, as 
reflected in national quality and credentialing standards.
    f) Logistics--A requirements-driven and accountable requisition, 
receipt, reconciliation and distribution (R3D) process, embedded within 
the MoD and MoI logistics systems and aligned to ANSF clinical needs.
    The vision driving the planning efforts, and the Afghan Healthcare 
System development effort overall is ``quality warrior care, from point 
of injury through a professional, ethical, effective and efficieint 
medical system, to recovery and discharge, for the nation's 
defenders.''
    The ANSF Healthcare System Development Support Plan will be one of 
the foci of a DODIG Special Plans and Operations (SPO)-led assessment 
planned for March 2013.
    Mr. Cooper. Describe the new medical logistics plan for 
accountability for medical supplies.
    Ambassador Moorefield. In 2011, we observed a restructuring of ANSF 
medical logistics whereby the functions of requisition, acquisition, 
storage, transfer and disposition of medical logistics were transferred 
from the ANA Surgeon's General office to the MoD/GS G4 and the ANA 
Logistic Command. This action brought MEDCOM into compliance with MoD 
Decree 4.0 and was intended to improve and promote accountability and 
responsibility for medical supplies.
    We saw several examples of improvements in the medical logistics 
system during our recent visit to NMH. Specifically we observed that 
the medical logistics staff participated in training to ensure they 
were complying with directives in MoD Decree 4.0. Additionally, they 
provided training to other NMH staff who also are required to utilize 
the MoD logistic forms. Furthermore, we observed that U.S. mentors 
assisted NMH medical logistics staff in developing an automated system 
which helped the Afghans to properly account for medical supplies and 
pharmaceuticals in their warehouse. Although recently implemented and 
only 20 percent complete, the Afghans were excited and proud to display 
this new technology and their intent to complete the data entry 
allowing them to completely automate inventory control measures for 
their medical supply inventory.
    Mr. Cooper. Describe the personnel shortages of the NMH in more 
detail.
    Ambassador Moorefield. During our recent NMH assessment, we 
observed personnel shortages in the pharmacy and on the patient care 
wards.
    The Pharmacy at NMH is authorized five pharmacists according to the 
1391 Tashkil and they have five pharmacists onboard. However, we 
observed that the pharmacy was extremely busy due to the high patient 
volume. NMH is a facility with an average daily census of 260 patients 
and has a bed capacity for 410 patients. We believe they could use 1-2 
additional clinical pharmacists who would be dedicated to dispensing 
pharmaceuticals to patients and providing pharmacy oversight of the 
inpatient wards.
    Additionally, we noted that several of the busiest inpatient wards 
experienced nursing personnel shortages. Specifically, the Orthopedic 
Ward (mostly war-related injuries) had 45 patients and only 6 nurses 
assigned filling 13 positions that were authorized on the NMH 1391 
Tashkil. However, at the time of our inspection visit, there were 126 
Nursing positions at NMH with 97 filled and 28 vacant for a fill rate 
of 77.6%, a significant improvement in staffing compared to our 
assessment in 2010 in which we noted a nursing fill rate of 51.5%. 
Nonetheless, the nursing staff shortages that still exist are in key 
medical support areas which may affect the quality of care and safety 
of patients.
    Mr. Cooper. Describe the problems regarding security of controlled 
pharmaceutical substances in more detail.
    Ambassador Moorefield. DODIG conducted an audit of the ANA's 
pharmaceutical distribution, which was published on May 7, 2012. One of 
the discrepancies noted at NMH during this audit was that controlled 
pharmaceuticals were not secured separately from uncontrolled 
pharmaceuticals. NMH took corrective action based on the report's 
findings and removed the controlled pharmaceuticals from the open 
shelves in their pharmacy stock room where they were stored with 
uncontrolled pharmaceuticals. Additionally, NMH obtained a storage 
locker where they placed all the controlled pharmaceuticals and locked 
the container per their regulations.
    However, during our visit in July 2012, we noted that this storage 
locker, although an improvement of the previous method of storing 
controlled substances, was not properly secured to the floor to ensure 
that it could not be easily removed. Our understanding is that NMH is 
already working on fixing this problem based on the recommendations we 
made during our out-brief to the command in July.
    Mr. Cooper. Describe the problems regarding equipment transfer and 
repair in more detail.
    Ambassador Moorefield. During our July 2012 visit we noted that 
some wards needed additional medical equipment such as patient monitors 
and IV pumps. We observed that some wards had equipment that was not 
used 100% of the time, and other wards did not have access to a 
particular piece of equipment when it was periodically needed. It was 
explained to us that accountability of medical equipment is taken very 
seriously among the Afghans and wards are possessive of maintaining 
control over the equipment they have assigned to them on their Tashkil. 
Consequently, the wards do not easily share medical equipment that may 
be needed for patient care on other wards. We will recommend in our 
report that NMH reassess the accuracy of the amount and distribution of 
medical equipment listed on the Tashkil and develop policy/procedure 
which enable loaning of medical equipment among the different patient 
wards. We also made this recommendation to the Hospital Commander, ANA 
Surgeon General and Assistant Minister for Health Affairs.
    Additionally, we noted that NMH continues to have challenges with 
the maintenance and repair of their medical equipment. This was due, in 
part, to a lack of qualified medical equipment repair technicians. NTM-
A initiated a contract to support NMH with medical equipment repair in 
2011 due to a lack of qualified ANA medical equipment repair 
technicians. However the Afghan company under contract did not perform 
the work that was required. Due to the contractor's non-compliance, 
work on this contract was discontinued in July 2012.
    In 2011, the ANA Armed Forces Academy of Medical Sciences (AFAMS) 
developed a 12 month curriculum, with U.S. and Coalition support, to 
train ANA soldiers as bio-medical equipment repair technicians. The 
first set of students have completed the didactic portion of the 
training and are now involved in the 2nd phase of the training where 
they participate in hands-on training maintaining and repairing 
equipment at ANA medical facilities. 10 of the 21 ANA soldiers who 
completed the first phase of training were assigned to work at NMH in 
June 2012.
    Mr. Cooper. Describe your concerns regarding the plan for medical 
monitoring beyond 2013 in more detail.
    Ambassador Moorefield. ISAF released the ``ANSF Healthcare System 
Development Support Plan'' in response to the COMISAF OPLAN 38302 in 
December 2011. Accordingly, NTM-A has developed a coordinated plan to 
guide the efforts of medical mentors/advisors as they work with their 
ANSF partners to transition to Afghan-led healthcare facilities. The 
objective for transition is as follows: ``An interdependent, 
professionally-led ANSF Health Function which generates and sustains 
sufficient police and army medical personnel, infrastructure, services 
and logistics capabilities, with accountable and effective health 
system that support the ANSF''.
    We have reviewed ISAF's plan and NTM-A's supporting plan, which 
includes objectives and milestones for the development of the Afghan 
healthcare system for 2012, 2013 and 2014. ANA hospitals, under the 
mentorship of U.S. and Coalition forces, are beginning to achieve 
success in demonstrating their readiness to transition.
    According to an NTM-A assessment conducted in June 2012, NMH 
received an overall rating which indicated that they are capable of 
executing functions with coalition oversight only. Furthermore, the 
NTM-A plan identified the third quarter of Calendar Year 2013 as the 
window for the transition of NMH to an ``Afghan-led'' hospital.
    Given the successes of NMH in working towards transition, we have 
asked NTM-A/CSTC-A to define a plan for the medical mentoring mission 
beyond the transition to NMH-lead to ensure the continued success of 
NMH and the ANSF Healthcare system, in general.

                                  
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