This qualitative study utilized seven key informants’ interviews among foreign Health Attachés accredited to the United States, and U.S. Health Attachés accredited to foreign governments. The selection criteria and recruitment of Health Attachés began in 2013, with all interviews completed between 2013 and 2014, and was limited to U.S. government (USG) Health Attachés and foreign Health Attachés accredited to the U.S. Government. As stated in our study definition, Health Attachés are highly specialized core GHD practitioners representing the interests of state level actors and are few in number, and thus our inclusion criteria limited the number of potential study participants to currently practicing core GHD practitioners [12]. During the period of data collection, there were only 13 individuals eligible for inclusion in the study population. While not all agreed to participate, we were able to evaluate non-participants’ stated reasons for declining to participate. This study was approved by the Institutional Review Board at the University of California, San Diego and San Diego State University (Protocol #1538089).

Given the small population eligible for this study, we contacted all eligible professionals who met our inclusion criteria. We conducted semi-structured interviews with all those who agreed to participate, recording and analyzing reasons for non-participation. Interviews were conducted face-to-face if possible, or administered over the phone when foreign travel was not practical. For participants located in the Washington D.C. area, interviews were arranged at a time and location convenient for the participant. For participants not located in the Washington, D.C. area, interviews were conducted over the phone at a time that was convenient for the research participant.

Informed consent was obtained from all participants and included permission to record and transcribe the interview. Interview notes were taken and incorporated into the narrative transcript. All participants were permitted an opportunity to review and clarify any part of the interview text before finalizing the transcript. Participant incentives were not offered in this study. Since all subjects’ names, titles, addresses, and respective country mission or embassy were publicly available, no promise of anonymity was possible, and while no names were reported in the analysis or reporting of results, no degree of anonymity was possible. Specifically, we identify all quotations and references to participants’ responses by only the embassy or country and the identity of the individual respondent is not included in the analysis, or the reporting of any results. These issues were covered in a consent form which was administered and consent obtained prior to starting the interview process.

A priori themes were drawn from the literature and used to develop the interview guide [1, 17, 18]. We focused on six domains related to the practice of GHD [19]. These domains represent gaps in the GHD literature and have not been previously described by practicing Health Attachés [20–22]. These domains included:

Health Attaché office and organizational structure, including their purpose, scope, and definition of GHD;

The complete interview guide is attached in Additional file 1.

All audio-recordings were transcribed verbatim. Transcripts were uploaded into MAXQDA for analysis. The first author (MB) and a second author (JB) reviewed all notes and transcripts and participated in the coding process. Transcripts were first read and reviewed to develop an understanding of the content and to identify emergent topics/themes [23]. Open codes were created from these emergent themes [23, 24]. These themes were combined with our a priori codes, as derived from our review of the literature, and compiled to create a codebook. The codebook included a description of each code’s content, inclusion/exclusion criteria, and a text example. Transcripts were then coded separately by the first author and second author. After coding was completed, transcripts were reviewed for discrepancies, resolutions discussed, and the final codes were applied to the transcript of the interviews.

“I am the ambassador’s primary advisor on health issues and coordinating representational or policy related issues in the health sector.” -- U.S. Health Attaché India

All participants stated that their primary role was to act as the main advisor to the ambassador and the overall Mission on health matters in addition to managing health related activities. Most of the Health Attachés were solely part of a bilateral mission, meaning the purpose of the embassy is primarily to maintain a formal relationship, codified in agreements, between a sending and receiving government. However, in two cases, E.U. and Geneva, the Health Attaché was part of a multilateral delegation. As such, they represented their respective sending government to a multilateral institution. The U.S. Health Attaché in Geneva is part of the U.S. Mission to the United Nations, with a focus on the World Health Organization (WHO). The E.U. Health Attaché represents the European Union, and supports and interacts with the 28 E.U. country Missions’ resident in the United States, as well as represents the E.U. to the U.S. Government and the diplomatic community in the Washington, D.C. area. Both multilateral relationships are codified in formal agreements within their constituent institutions.

Interestingly, no Health Attaché was part of a dedicated health section in any Mission (Table 4). Instead they were embedded in other embassy sections, such as the Commercial (E.U), Economic (Canada), Science and Technology Section (Italy), Environment, Science, Technology and Health (ESTH) sections, or Political sections (U.S). The Health Attachés in the U.S. Embassies in China, India and South Africa, and the Canadian Health Attaché were the only participants who had their own employees and a unit dedicated solely to public health, rather than acting as a solo professional. Health Attachés without a dedicated health section had a direct reporting pathway to either the Ambassador, or the Deputy Chief of Mission. In the case of Canada, Italy, and the E.U., the Health Attaché reported through another section head of the Embassy. In Italy’s case, the Attaché reported to a Science and Technology Section head, in Canada’s case to the Economic Section Head, and the E.U. case to the Commercial Section head. However, all also maintained a reporting line to the Ambassador. It is interesting to note that as reported by the Geneva U.S. Health Attaché, in the U.S. DOS organizational structure of a Mission, if no ESTH section or officer is present, public health matters normally fall to the Economic Section, despite the Geneva Health Attaché sitting historically in the Political Section. However, in all cases, there was also a direct reporting relationship to their national public health authority in their home countries. This represents a double reporting line to Mission leadership (a primary reporting line) and a domestic public health agency/ministry (a secondary reporting line), reflecting the dual role in organizational structure and reporting responsibilities of Health Attachés.Table 4

Foreign and U.S. Health Attachés reporting relationships and Section Size

As demonstrated in our literature review, GHD does not have standardized competencies as a field or required training for practitioners, and as such, no Health Attaché reported being trained to be a Health Attaché. As stated by the Canadian Health Attaché, “One of the deficiencies in global health diplomacy is not having a common language.” The Canadian Health Attaché lamented that the profession has to create its own best practices and common terminology while also identifying needed skills and gaps in training for successful careers. Participants voiced that there were four main skills needed for successful GHD practice: diplomatic and negotiation skills, public health and scientific knowledge, an understanding of their Mission’s overall priorities, and cross-cultural competency.

Health Attachés cited numerous specific skills developed during their respective careers that contributed to various professional successes while serving in a diplomatic Mission. The Italian Health Attaché highlighted the need for technical skills in the field of health.

“[You need a] strong technical background. Sort of a professional diversification…because the real challenge is to understand what science means, to be able to read and understand…areas of interest by different scientists…” —Italy Health Attaché

The Health Attaché from the E.U. referred to the importance of negotiations skills when working on the Trans Pacific Partnership (TPP), a trade agreement among 12 Pacific Rim countries, which has undergone years of negotiations and is currently in a state of flux. She cited simulation games used to develop her negotiation skills as part of her career development.

“Sometimes you have bad arguments, or you are sent into a mine field which you can't defend… we make a difference in our work with simulation games about negotiation so you [can test various] different outcomes.” -- E.U. Health Attaché

The U.S. Health Attaché to China highlighted the subtle professional skills and cultural understandings needed in diplomatic negotiations.

“In international negotiations, it's all about postures. In addition to body language, listening, it's also cultural sensitivity and, of course, nobody can learn everything about every culture but instead of trying to put forward your position too quickly... even playing poker might help too.” – U.S. Health Attaché China

To be effective in their roles, Health Attachés reported that they engage in daily activities of tracking existing and negotiating new agreements, organizing visits and attending meetings, drafting briefing documents, and meeting counterparts, collaborators, and other actors vested in public health issues in the country or region of assignment. As stated by one U.S. Attaché, all activities while serving as a Health Attaché require maintaining and building relationships, the bread and butter of diplomacy.

“Relationship building is a key component of my responsibilities being the sole HHS representative in this country and this part of the world. The relationships are critical to my effective work and that’s a very important part of my job.” – U.S. Health Attaché South Africa

Health Attachés reported that they must be able to create and draw upon relationships within their host country to advance the priorities of their Mission while searching for an intersection of mutual interests, for both the sending and host governments. Part of building and/or maintaining these relationships comes from chairing and attending committees, working groups, or ad-hoc coordination efforts on health issues and collaborations in the country or region of assignment. Relationships built from these events are then utilized in meetings that manage or maintain requirements related to existing agreements, renew health agreements, and establish new partnerships, accords, or agreements codifying mutual requirements and benefits among parties.

Moreover, each Health Attaché reported employing knowledge gained from these relationships and priorities when contributing to internal planning documents with the Mission, or crafting briefing documents, memos, and talking points or speeches for Mission and governmental leadership. As the U.S. Health Attaché in Geneva mentioned, sometimes “we have a need for key elements to be respected, like human rights, inclusion of sexual and reproductive health services … provided to women and a range of things [that need to be included].” Since Health Attachés have established relationships with other country representatives, they reported being effective in identifying and exploiting areas of agreement and implementing mutually beneficial health initiatives, such as an innovation initiative supported by the Canadian Embassy in the below example:

“That was a good example of global health diplomacy in that we’re providing seed money to these entrepreneurs, medical entrepreneurs in their own countries that would then spin off to a [business to] benefit the country.” -- Canada Health Attaché

Health priorities are also part of health portfolios with established goals and objectives of the Mission in the health sector, and are typically part of a larger Embassy strategic planning process, with several foreign policy goals. While most Mission plans are not available for public review or comment and remain unpublished, they are sometimes shared with government counterparts, and are often important tools to advocate for allocating resources, such as the U.S. Government’s President’s Emergency Plan for AIDS Relief (PEPFAR), which provides five-year strategic plans that in turn guide development of annual Country Operational Plans in collaboration with the host country [25, 26]. Another example is the European Union’s “Third Health Programme (2014–2020)” which involves all countries in the Union, and has objectives that impact global health. This plan, developed from a protracted and deliberate consensus-building process, has a health component to engage E.U. member states, universities, industry partners, and the general public, and is published online every six years [27].

Another example of a multi-year consensus process involving Member States engaged in GHD is the preparation process for resolutions for the World Health Assembly, the convening body of the WHO [28]. In describing one negotiation, the U.S. Health Attaché remarked:

“This one ended up being about two years of negotiations; from 2010 to 2012 … we built a consensus around a public health approach to dealing with substandard and counterfeit medicines. We created a new member state mechanism which is effectively a subsidiary body of the World Health Assembly to kind of manage and oversee WHO engagement on counterfeits.” -- U.S. Health Attaché to WHO Geneva

One Mission priority, cited by all seven Health Attachés, was global health security. As the Italian Health Attaché commented:

“We also tend to react on the spot by different interests depending on different priorities; Ebola these days [and] global health security is taking priority.” -- Italy Health Attaché

The participants stated that health security, found in most global health initiatives, requires continuous discussions with diplomats and other government officials as well as many representatives within the private sector. The Global Health Security Agenda (GHSA), is a multi-state collaborative that was initially launched by the United States in partnership with WHO and is now governed by a multi-country steering group that includes several international organizations as advisers. It also includes the participation of foundations, non-governmental organizations, and civil society, all with the common goal of accelerating implementation of the IHR [29]. Reflecting the importance of health security in the health diplomacy portfolio, Health Attachés from each of the seven countries were all active participants in multiple GHSA meetings and activities.

During the study data collection period, four GHSA events were held. These were located in Washington, D.C. in February 2014, Helsinki in May 2014, Jakarta in August 2014, and the White House in Washington, D.C. in September 2014 [30]. All seven participants attended one or more of these meetings and were involved in inviting and preparing attendees on health-related security issues. In the case of China, India, and South Africa, the diplomatic exchange also involved a demarche concerning attendance at a forthcoming GHSA meeting [31]. A demarche is a formal communication from one government, to another government, usually hosted through respective foreign ministries, and often involves a face-to-face meeting to ensure the context of the communication is clearly communicated.

All seven participants strongly believed that GHD as a field and practice would continue to expand and grow in importance in the future, and consequently must be supported and resourced accordingly. A challenge cited by India, South Africa, China, Geneva, Italy, the E.U. and Canada, was a lack of resources to maintain the requirements of their job, while at the same time managing increasing demand for their services and an increasing workload. The U.S. Health Attaché in South Africa succinctly summarized this point:

“The amount of international health engagement continues to grow, whether that’s bilateral relations or mutual recognition of interests in Health Security, or just plain globalization [that] makes the world smaller, we are going to continue to do more things together…the amount of health diplomacy engagement required to manage and facilitate is a challenge.” -- U.S. Health Attaché South Africa

As asserted by all the participants, GHD is critical to ensuring the success of multi-state engagement on health issues.

All Health Attachés cited that as the practice and use of diplomatic activities involving health continue to grow, workloads likewise increase, but did not anticipate that resources would follow suit. Specifically, participants identified a lack of funding to hire additional staff, support travel, or host meetings or workshops. As stated, only India, China, South Africa, and Geneva had more than one employee in addition to the Health Attaché. Given this, they predicted that meeting the increasing demands of diplomatic activity in health will be a critical challenge to overcome in the future.

Finally, in addition to resource challenges, Health Attachés in India, South Africa, and China all cited that there is a perceived fundamental tension between the goals of public health, which requires tackling public health threats by partnering with nations around principles of health equity, involving shared responsibility and collective action, and those of foreign policy, which emphasizes national interests and often actions of protective isolation.

“…they have very different priorities than we do or they have very different objectives than we do…that there is anybody at the table who has very different objectives than we do… I think that’s a problem. Certainly something that needs to have some sort of reconciliation…” – U.S. Health Attaché India

All participants cited that despite this tension, health continues to be present in nearly all foreign policy goals, be them commercial, trade, or security, and this will mean a greater need for negotiations by diplomats with competencies in health engagement within a foreign affairs environment.

Our study’s main weakness was our limited sample of respondents and as such we did not explicitly separate results between USG and foreign Health Attachés. As reported, this study focused only on core GHD practitioners and this population of state actors is by definition very small in number. While we would have preferred to interview a greater number of foreign Health Attachés to better understand how their roles differ from those of U.S. Health Attachés, we only included diplomats who were responsible for health as indicated by their diplomatic title as listed on the Diplomatic List, which is the source of all core GHD practitioners.

Any study on core GHD practitioners should employ this sampling method as a baseline. Though future studies could build on this definition and expand the inclusion criteria (including potentially to multi-stakeholder and informal health diplomacy actors) and stratify results based on category/characteristics of Health Attaché, this was beyond the scope of the study objective given the primary focus to describe the experience of a core GHD practitioner. Our interviews were also completed in 2013–2014, limiting the generalizability and applicability of findings given subsequent changes in the political and global health policy environment that may influence health diplomacy and the practice and perceptions of Health Attachés.

Additionally, we were unable to travel for this study, and were unable to include health diplomats that may be posted in other countries (e.g., a Canadian Health Attaché posted in China). This limited our findings to Health Attachés with a United States nexus. Future studies could be designed to expand this sampling frame to other jurisdictions to better balance any potential location-based bias, and could also include case studies illustrating successes and challenges of Health Attachés in their respective careers to better illustrate thematic findings. Despite these limitations, the variety of participants each had a unique perspective, with many common points and shared experiences, that generalization to the larger population are appropriate, and provide a first in-depth qualitative analysis of core GHD actors, and as such is a critical contribution to helping mature and develop this expanding and critical field of practice.