Exploring global health diplomacy in Iran: insights from experts in health and foreign policy
The literature on global health diplomacy (GHD) is scarce, particularly in the context of low- and middle-income countries (LMICs). This study thus explores the GHD concept, content, policy-making process and influencing factors in Iran from the perspectives of key health and foreign policy-makers.
This is a qualitative study using conventional content analysis. We conducted in-depth, semi-structured interviews with 29 experts from the health and diplomatic sectors in Iran, supplemented by five focus group discussions. We used purposeful and snowball sampling techniques to identify key informants and continued data collection until saturation was achieved. Data analysis was facilitated by MAXQDA V.12 software.
A lack of consensus emerged among the health and foreign policy-makers regarding the definition and importance of GHD, and the varying interpretations of the concept were influenced by the level of knowledge, personal experiences and professional backgrounds, values and belief systems of participants. GHD was found under a relative influence of—both explicit and implicit—ideological and political challenges in Iran. The excessive emphasis on the ideological aspects and the dominance of political, security and military considerations over other foreign policy objectives have been identified as a major barrier to achieving the desired policy goals. Health integration into foreign policy has often been reactive and crisis-driven, rather than planned and proactive, failing to adequately identify or optimise available domestic and international opportunities. Additionally, participants singled out the lack of an inter-sectoral institution or steering council to improve policy coherence and enhance coordination across and within sectors.
A common understanding of GHD is expected to pave the way for the implementation and effective achievement of broader foreign and health policy goals in LMICs, such as Iran.
Global health diplomacy (GHD), a subset of new public diplomacy,1–4 emerges in response to the evolving needs of the global landscape.1 5–7 Here, non-governmental organisations and civil society act as pivotal players in shaping norms, international regulations and policies.8–10 It represents a qualitative transformation in diplomacy, increasingly prioritising soft power over hard power. Reforming GHD embodies an interdisciplinary construct6 11–13 that seeks to integrate diplomatic acumen with public health expertise and technical knowledge.14 15 Although boasting a legacy of over 160 years within international cooperation,16 GHD has only recently gained prominence in the political lexicon of health and foreign policy, attracting significant attention from policymakers across diverse fields.1 17
Defined as “multi-level, multi-actor negotiation processes that shape and manage the global policy environment for health”,18 GHD also involves “policy-shaping processes through which state, non-state and other institutional actors negotiate responses to health challenges, or utilize health concepts or mechanisms in policy-shaping and negotiation strategies, to achieve other political, economic or social objectives”.2 Although GHD is the term most frequently used in this study, other related terms include medical diplomacy, health diplomacy and disease diplomacy. While these terms can sometimes be used interchangeably, they each have distinct meanings. GHD broadly includes the actions and practices associated with the concept. In contrast, health or medical diplomacy is more focused on the specific activities of an individual state.19 Disease diplomacy aims to negotiate strategies for enhancing the global framework for disease surveillance and control.20
Currently, GHD plays a vital role in harnessing soft power resources rooted in cultural values, political ideologies and institutional frameworks.3 Such internal empowerment mechanisms can bolster national power and authority, diminish vulnerabilities, safeguard public health during crises and sanctions and facilitate the achievement of national objectives in international relations. However, despite the increasing interest of politicians, policymakers and researchers in GHD in recent years, the field lacks the necessary coherence and stability.21 Furthermore, there remains significant divergence in perspectives among activists within this sphere, leading to an absence of consensus regarding the concept itself.2 17 19 22 While health diplomacy has gained recognition within high-income nations, it remains underexplored and overlooked and placed lower on the hierarchy of national priorities in the low- and middle-income countries (LMICs), that is, Iran. The volume of scholarly work produced domestically on this subject is limited, often falling short of a comprehensive analysis.23 A primary gap in the literature on GHD is the inadequate portrayal of its nature and elements.3 As a result, this concept is often overshadowed by other terminologies in both practical and academic contexts, leading to confusion with related concepts such as disease diplomacy, medical diplomacy, communication and international health cooperation.17 19 Notably, the discourse surrounding GHD lacks robust theoretical and analytical frameworks and has struggled to establish clear connections with the theoretical paradigms of international relations, as highlighted by prior studies.2 17 19 Various governmental entities have initiated actions under the umbrella of GHD. However, divergent interpretations and understandings of this concept among political and executive actors have resulted in fragmented policies and inefficient coordination, ultimately hindering the advancement of bilateral and multilateral international relations in health.
Understanding GHD in diverse contexts, particularly in non-Western settings such as Iran, is crucial for developing globally applicable and culturally sensitive frameworks. Focusing on Iran, this study contributes to this understanding by providing insights into the perceptions, challenges and opportunities associated with GHD implementation in a nation facing unique political, economic and ideological pressures. These insights can inform the development of more effective and inclusive GHD strategies applicable beyond the Iranian context. This is particularly relevant given the close intertwining of health policies, foreign relations and international cooperation in Iran.
As the second-largest nation in the Middle East, Iran has a rich history of healthcare, transitioning from traditional practices to modern treatments. Today, it has a population of over 80 million, predominantly living in urban areas. Despite facing environmental challenges, natural disasters, disease outbreaks and a shift towards non-communicable diseases, Iran has made significant investments in various health initiatives and medical expertise, achieving near self-sufficiency in pharmaceutical production. These achievements are noteworthy, considering the country’s history of regional conflicts, war and international sanctions.24
In an attempt to clarify the evolving concept of GHD2 11 and enhance the theoretical knowledge within the political and scientific community, this work investigated the development and application of GHD as perceived by the health and foreign policymakers in Iran. The findings offer valuable lessons for other LMICs facing fairly similar challenges, leading to a more nuanced and comprehensive understanding of GHD’s global application.
This is a qualitative research study using conventional content analysis.25 The aim was to explore the perceptions, content, policy-making process and contextual factors influencing GHD among health and foreign policy experts in Iran. We conducted 29 face-to-face semi-structured interviews and five focus group discussions (FGDs) with key informants identified through purposive sampling and snowball techniques. All interviews and FGDs were conducted in Persian, the first language of all interviewees. The response rate was 60%. Five FGDs were conducted to supplement to verify the findings from the individual interviews and explore shared perspectives and consensus on GHD among different groups of experts within the health and foreign policy sectors.
The study participants comprised experts and officials who were somewhat familiar with diplomacy and health diplomacy in Iran, coupled with teaching and professional experience in these domains. Table 1 presents the characteristics of the key informants.
Characteristics of key informants (n=29)
The first author (ST) conducted the interviews. We used a generic interview guide, prepared and validated by the research team, and conducted all interviews and FGDs in person. On participants’ permission, we digitally recorded all interviews and FGDs and proceeded until we reached data saturation, indicated by the absence of new codes, categories or themes emerging in the last two interviews. All interviews were transcribed verbatim by the first author (ST).
Following data analysis, the primary codes and categories were presented to a subset of participants (n=7) for review and feedback via email. This member-checking process aimed to ensure the accuracy and trustworthiness of our interpretations. Intra-subject agreement method was employed to ensure reliability.
We used MAXQDA V.12 software for data categorisation and management.
Patients were not involved in the research process and there was no public involvement.
The study synthesised insights from interviews with the key stakeholders and informants in Iran to outline the concept, its integration into foreign policy, and the content, process and contextual factors influencing health diplomacy in Iran.
Our findings revealed a lack of consensus on the concept of GHD among Iranian stakeholders, with participants expressing diverse interpretations influenced by their professional backgrounds and personal experiences. This diversity in understanding echoes the complexities seen in other emerging scientific concepts, which often require deeper discourse.
Each of us, who have a responsibility in this field, have a different way of looking at defining or explaining this issue, reflecting the individual influences of work experience and knowledge levels. (Participant 24)
How this term is meant depends on who wants to define it […] each of us views a special part of this issue or phenomenon and from a unique angle and perspective appropriate to our respective fields. Therefore, none of these perspectives are wrong; they simply reflect different ways of looking at this field, which is too broad. (Participant 18)
We detected little homogeneity regarding the definitions of health diplomacy among participants, mostly related to their different ideologies and personal values. One expert noted:
… its meaning is influenced by the thoughts, opinions, and special values of the person who defines it. (Participant 3)
Moreover, many experts criticised the absence of significant research into health diplomacy in Iran.
This concept has not been explained and scrutinized as much as it deserves. (Participant 25)
The interviewees described GHD as a complex, dynamic, multifaceted and multi-layered process, achieving which needs a clear understanding of its meaning. Although this concept is often used as if it represents a well-defined concept common to all stakeholders, it still suffers from conceptual ambiguities and a lack of illustrative examples, and resolving these ambiguities requires further investigation and research in this field.
Health diplomacy is a concept whose exact meaning has not yet been explained, and there is considerable room for discussion. Its articulation evolves according to the contextual conditions that influence the concept, its scope, applications, and stakeholders. This concept, akin to many fundamental ideas in international relations and health care, remains one of the most nebulous. It is challenging to delineate it from other closely related concepts, and accurately identifying its exemplars is problematic. (Participant 19)
Several participants in the current study expressed a critical perspective, noting that, apart from brief mentions by some key decision-makers in news outlets, meetings or conferences, there has been a lack of serious attention to health diplomacy within the country. They highlighted that comprehensive research on this topic has not been conducted domestically. Furthermore, the absence of direct reflection of health diplomacy in national policies and macro-level documents supports the assertion that health diplomacy is neither systematically defined nor prioritised on the agenda of the country’s policymakers.
There is currently no specific policy framework governing this area in our country; consequently, the concept has not been adequately explained or examined. Official reports from the country often reflect cursory mentions, such as the signing of a memorandum of understanding or a cooperation agreement with another nation, or highlight meetings that occurred during the COVID-19 pandemic with heads of governments and international institutions. However, these instances do not constitute a comprehensive treatment of the concept. (Participant 25)
Several experts asserted that diversity, plurality of meanings and the transformation of concepts are fundamental characteristics of the field of international relations. They believed that health diplomacy, akin to several other concepts within this domain—such as diplomacy, power and security—has not fully benefited from theoretical and meta-theoretical advancements, nor from changes in the operational frameworks of governments and international institutions. Furthermore, it is crucial to recognise that the definition of health diplomacy should avoid conflating its meaning with synonymous or closely related concepts, such as ‘disease diplomacy’, ‘medical diplomacy’, ‘International Cooperation for Health’, ‘International Health Diplomacy’, ‘mask diplomacy’ and ‘vaccine diplomacy”. Although these terms are sometimes employed interchangeably with health diplomacy, each possesses its distinct meaning and concept. The indiscriminate use of these synonyms can lead to a diminishment of the meaning and conceptual scope of health diplomacy, thereby obscuring its specific significance within the broader discourse.
The terms “medical diplomacy”, “mask diplomacy”, “disease diplomacy”, “vaccine diplomacy”, “international cooperation”, and “health diplomacy” are deeply intertwined, complicating efforts to differentiate health diplomacy from other related concepts. While there are nuances among these terms, they are frequently utilized interchangeably, despite the existence of specific, specialized meanings for each. (Participant 19)
The interviews revealed that varying definitions of health diplomacy are often influenced by ideologies and values, detracting from a coherent conceptual understanding. This conceptual vagueness poses significant challenges to effectively developing and implementing health diplomacy initiatives. One expert stated:
Health diplomacy is a concept whose exact meaning has not yet been explained and there is a lot of room for discussion … (Participant 19)
Several participants in the study expressed the view that while the concept of ‘health diplomacy’ is not new and has deep historical roots in human society and civilisation, each of the associated terms holds specialised meanings. They noted that none of the commonly used terms is precisely equivalent to ‘health diplomacy’ or ‘global health diplomacy’. Furthermore, it was observed that most experts involved in the study did not articulate the subtle yet significant differences among these concepts.
Frequently, shifts and developments in domestic and international policies result in changes to fundamental concepts. However, it cannot be asserted that this term diverges significantly from prior actions and efforts; rather, it encompasses a broader scope than other commonly employed terms. (Participant 2)
Moreover, “health diplomacy” is often used interchangeably with “medical diplomacy”. These concepts are complementary, making it difficult to delineate strict distinctions between them. Nevertheless, they exhibit subtle differences, with health diplomacy appearing to be the most advanced of these terms. (Participant 17)
Participants highlighted the importance of GHD, which includes a multidimensional perspective on health determinants. This perspective emphasises the need to address the root causes of diseases and health inequalities, which are often influenced by social, economic, political, cultural and environmental factors. A comprehensive approach aids researchers, health policymakers and stakeholders in avoiding sectionalism and formulating integrated policies that foster national cohesion and promote healthier public policies.
Health diplomacy is a comprehensive and multilateral approach that helps policymakers and decision-makers gain a better understanding of the social, economic, cultural, environmental, and governance factors affecting health. It is essential to strengthen communication between institutions to find effective solutions to address inequalities and injustices through unity and coherent policies. (Participant 1)
Participants mentioned that health diplomacy in Iran lacks a coherent, long-term strategy, often reacting to crises rather than having a proactive agenda. Several experts emphasised the need to consider health as an integral part of foreign policy and not merely a tool to achieve other diplomatic or political goals.
Health diplomacy in Iran is mostly not a specific and pre-planned policy. There is no road map for it at all. The current programs tend to be weak and often reactive, formulated with a short-term focus in response to immediate crises, such as natural disasters or shortages of medical supplies. This approach diverges from a strategic plan aimed at purposeful identification and effective usage of both domestic and international capacities. (Participant 19)
There is almost no policy, road map, and targeted planning for it. (Participant 25)
The participants, particularly foreign policy experts, highlighted the absence of a defined structure or institution for health diplomacy policy in Iran. They suggested that the Ministry of Health should oversee health diplomacy and advocated for the establishment of a strategic council comprising various stakeholders to develop policies in this area. They proposed that the Minister of Health should lead the council, with representation from other ministries. This mechanism could enhance inter-ministerial collaboration and facilitate the transfer of technical expertise.
For effective health diplomacy, a dedicated council should be formed to discuss issues slated for international negotiation. This council would address Iran’s negotiating positions, make decisions, and formulate policies to be communicated to the negotiating team. This process enables negotiators to better assess how much they can compromise on the interests of other parties to achieve agreements. (Participant 12)
Now, the lack of such an institution is a big flaw and challenge. I believe that there should be such an institution so that a policy can be formulated as a national policy regarding certain issues, and they communicate that policy to the negotiating team. (Participant 14)
Several interviewees stated that in health diplomacy, negotiation skills are as crucial as health expertise, showing a consensus on the need for well-equipped diplomats who can bridge the gap between public health policies and international relations. They emphasised that it is unreasonable to expect foreign diplomats to possess comprehensive knowledge of health issues without guidance from experts within relevant ministries. The individuals involved in the proposed strategic council should have adequate expertise, with selection criteria based on qualifications.
During the negotiations … there are many cases where the Ministry of Foreign Affairs was alone in the negotiations, on the one hand, it did not have accurate technical information and knowledge of health issues, and on the other hand, there were no policies formulated inside the country that the negotiator knows what to defend. (Participant 18)
According to the interviewees, health diplomacy policy in Iran contains various dimensions, including public health administration, international cooperation, and strategic negotiations to improve health outcomes.
Health diplomacy must integrate public health objectives with foreign policy. (Participant 4)
Participants stated that the content of the policy is based on both local needs and international obligations, which require alignment with global health programmes such as those established by the WHO and other critical international protocols. This content includes creating frameworks and strategies that enable Iran to effectively engage with stakeholders in GHD. They stated that the provision of vaccines during the COVID-19 pandemic significantly highlighted the importance of strengthening health diplomacy.
Some participants pointed to the intricate relationship between health and social security functions, which has intensified and diversified in recent years. Foreign policy objectives related to health, global security and peace influence health outcomes, while health can also steer foreign policy priorities and objectives. They stated that effective health and foreign policy initiatives must be integrated. One participant stated:
You must not see these areas separately. They are a package; if the security situation improves, it will definitely and easily shift to other priorities. (Participant 2)
The interdependency among health, foreign policy, and trade has increased. The foreign policy of any nation reflects its domestic policies, suggesting that changes in foreign policy require an internal policy shift. For countries like the UK, there is a strategy emphasizing that initiatives begin at home. (Participant 19)
Most participants agreed that the concept is a tool for consolidating bilateral, interactive and constructive relations between health and foreign policy. They assert that these confrontational relations extend beyond the mere promotion of health objectives; rather, they serve as a political instrument capable of achieving other goals and specific interests inherent to foreign policy.
There is a reciprocal relationship between health and foreign policy that strengthens each other. Health diplomacy is considered a diplomatic tool for achieving health goals and other national goals at the same time. Why do I say other national goals? The objective of policymakers and politicians in adopting a health diplomacy policy is not solely to improve health status. Governments also pursue additional goals through health diplomacy. (Participant 20)
All countries, especially developed nations and certain emerging powers, are investing more than ever in the field of global health while expanding exchanges and interactions in this domain. The aims of these diplomatic efforts and investments often include advancing the latent interests and objectives of national foreign policy. Nonetheless, this dynamic does not necessarily imply a neglect of humanitarian goals or an absence of genuine efforts to enhance the global health situation. (Participant 12)
Some participants defined health diplomacy as the adjustment and promotion of goals, programmes and policies related to health through the actions of the foreign policy apparatus. In this view, health should be a primary objective of foreign policy.
Health can also serve as a lever to promote foreign policy goals, such as economic development, tension reduction, political relationship enhancement, and overall peace. Conversely, foreign policy must incorporate health as a critical security issue and economic factor. (Participant 25)
According to most participants, Iran’s foreign policy has consistently contributed to health initiatives and the achievement of health-related goals. Alternatively, economic sanctions have, in some instances, led to other national considerations—such as security, military or economic issues—being assigned higher importance than health, humanitarian and environmental matters within the national political agenda. In any event, fluctuations have been observed concerning these priorities, influenced by domestic conditions and international dynamics; nonetheless, health has maintained its legitimacy and has remained on the national political agenda. Health has consistently been regarded as a political priority by politicians and national policymakers.
Health has always been an important issue and it still is … (Participant 12)
I believe that health has always been a goal for foreign policy. Of course, it has definitely been a tool in a few cases. But this is the institution of the Ministry of Foreign Affairs that has helped to improve the health status of citizens or participated in humanitarian measures and sending health aid. I want to say that as much as foreign policy has helped health, health has not helped our foreign policy. This may be true for Brazil, China, America, and Cuba, but it is not true for us, because the officials themselves do not know the domestic capacity, nor the international capacity, or our ideological and political positions do not allow health to be the goal of politics. (Participant 18)
In some governments after the revolution, such as Rouhani’s and Khatami’s, issues such as health, environment, scientific cooperation, and the economy gained importance alongside security issues. Why? Because the perspective of the individuals who led the government was one of interaction and cooperation, rather than tension and confrontation. (Participant 12)
… health has been an important issue for all the governments that have come to power. As a result, sometimes the situation really constrains the officials’ abilities, forcing them to make difficult decisions. After the sanctions, the country faced several significant problems, one of which was the damage to the economy. If health was initially a priority—say, ranked third—it may have been relegated to seventh place. (Participant 32)
Some participants criticised the passive nature of foreign policy on health and expressed concern that health diplomacy has not been systematically developed or integrated into national policy, reinforced by a lack of dedicated research or clarity around the term. Some have argued that the COVID-19 pandemic has caused a shift in awareness of international health cooperation, although no specific policies have emerged since then.
Health and the issue of healthcare have consistently been priorities; however, they have not been the foremost priority. The country is grappling with a series of challenges, and if we do not allocate resources and attention to these issues, we will inevitably face further problems that will adversely affect both security and the economy. (Participant 11)
I assert this with conviction: the primary focus must be on security, followed by the economy. The importance of health is diminished unless a crisis occurs that places lives in jeopardy. (Participant 6)
Health has not yet attained the importance it should hold within foreign policy. Utilizing health initiatives to advance national objectives is not inherently problematic; many countries that are now recognized globally as benevolent and justice-seeking have taken this approach. Nonetheless, this alone is insufficient. Foreign policy should ensure health in the same manner that it guarantees security. (Participant 14)
Most of the participants believed that the progress of health diplomacy in Iran requires a perspective that places health in national and international political agendas. They advocated for the institutionalisation of health considerations in policy making and foreign policy decisions, not merely as a tool of soft power to achieve other national goals. They stated that this revised approach could potentially lead to expanded diplomatic interactions related to health policy formulation and increased accountability among political leaders at the national and international levels regarding public health. They argued that for health to play an important role in foreign policy, political and security interests must be aligned with the support of strong political leadership and adequate mobilisation of financial resources.
This issue may be a little different in our country. In my opinion, it is the diplomacy and the foreign policy apparatus of the country that has helped health more than the other way around. Health must rise to the level of security issues; otherwise, it will be treated merely as a tool for achieving other foreign policy objectives. Diplomacy should promote health as a primary goal rather than a means to other ends. (Participant 13)
It was not that we had severe political differences with any country or that the official diplomatic channels had reached a dead end. After that, through healthy interactions, we were able to fix our economy and our international image, which was damaged by the Iran-phobia of the Westerners and the Saudis. We want to improve it to some extent, but nothing can be accomplished until the political relations are in good standing. (Participant 14)
Health is a tool of soft power. Introducing Iran’s international capacities and capabilities to the world can neutralize the endeavors of Western powers and certain regional countries attempting to undermine the country’s international image and foster Islamophobia and Shiaphobia. This approach could project a positive and realistic portrayal of Iran’s objectives in international interactions, thereby enabling the country to secure a more favorable position in both regional and global dynamics. (Participant 6)
Some participants asserted that the GHD policy lacks a coherent pre-planned strategy and is instead characterised by purposeful actions that do not adequately identify or optimally exploit available domestic and international opportunities. As a result, the policy has struggled to achieve its intended objectives of advancing national interests. Conversely, some specialists and experts in this field contended that national and ideological interests are not inherently in conflict; however, they identified an excessive emphasis on ideological aspects as a contributing factor that limits the country’s capacity to leverage opportunities within GHD.
Health diplomacy in Iran is mostly not a specific and pre-planned policy. There is no roadmap for it at all. The programs are very weak and ineffective and are often formulated with a short-term vision and for an immediate response to a crisis or shortage, such as natural disasters, lack of medical equipment and drugs, etc. This approach conflicts with a pre-planned strategy based on the identification and optimal use of domestic and international capacities. (Participant 25)
Political and ideological factors
Some participants noted that the conceptualisation and implementation of health diplomacy policy in Iran are significantly influenced by political issues and ideological considerations.
They argued that the absence of a cohesive plan and strategy, inadequate needs assessment, and insufficient identification of both national and international capacities for health diplomacy have hindered the country’s ability to effectively leverage opportunities. This limitation has restricted the scope of cooperation primarily to nations that share similar values. Although some experts contend that national interests and ideology do not inherently conflict. They believe that an excessive focus on ideological elements restricts the country’s ability to use opportunities in GHD.
The ideological nature of Iran’s foreign policy often clashes with the approaches of regional and global powers, which exacerbates misunderstandings about Iran’s foundational principles, creating barriers to cooperation. (Participant 25)
Our health policies are often seen through the prism of ideological beliefs, which sometimes complicates international engagements. (Participant 14)
Most participants stated that advancing health diplomacy requires placing health in broader national and international political frameworks and institutionalising health considerations in policy decisions and that foreign policy should focus on health as an end rather than a mere means to achieve other national interests to emphasise fundamentally. As a result, this approach can increase the accountability of political leaders towards public health.
For health to assume a significant role in foreign policy, it must be integrated with political and security concerns. Strong leadership and adequate financial resources can facilitate the expansion of health diplomacy. In Iran, some experts suggest that health diplomacy has benefited more from foreign policy than the reverse. Health should be prioritized as a central concern, rather than being instrumentalized to realize other foreign policy objectives […] health should be a goal in itself, not a tool. (Participant 12)
Moreover, there have been instances where, despite significant political differences with other nations, enhanced health interactions improved economic conditions and rehabilitated Iran’s international reputation.
Nothing can be done until the political relations are not good. (Participant 13)
Health, like a tool of economics or science and technology, has been used precisely to guide other goals in other political, economic, and security fields, and no government has ever sought to pursue the improvement of health. (Participant 1)
Health is a tool of soft power. Promoting Iran’s international capabilities can counter Western efforts to undermine its global image and foster Islamophobia and Shiaphobia. This strategy may provide a realistic depiction of Iran’s objectives in international relations, thereby enhancing its positioning in regional and global frameworks. (Participant 7)
Situational factors
Most participants expressed that health diplomacy often gains recognition in Iran only during significant health crises, such as the COVID-19 pandemic, which highlighted the necessity of international cooperation in safeguarding public health.
the Covid pandemic … caused us to see a change in the pattern of cooperation between countries. (Participant 8)
Cultural factors
Many of the interviewees stated that cultural factors and especially Iran’s Islamic identity have played a deep role in shaping the country’s health diplomacy, and these factors bring opportunities and challenges. Some of them stated that while religious beliefs can strengthen diplomatic relations with other Muslim countries, they also isolate Iran on controversial issues.
But the fact that we are a Muslim country, our religion of Islam and Shia religion and with a civilization of several hundred years helps us to create capacities to use diplomacy to secure national interests. Now we can use this capacity and expand the level of our relations with many Muslim countries of the third world. (Participant 5)
…, as an Islamic country, we have certain positions that are effective in our health diplomacy. There are topics that create distance between us and other nations. For instance, in negotiations at the World Health Organization concerning the health of homosexuals, Iran isolates itself from consensus, alongside countries like Saudi Arabia and Egypt. (Participant 7)
Issues like the circumcision of girls, which is prevalent in some African countries, have elicited differing views in our country […] Thailand proposed a resolution on the harmful effects of alcohol, which Iran could accept; however, terminology—such as referring to alcohol as ‘destructive’—created issues for us. Iran struggled to support a resolution that merely focused on the negative aspects of alcohol, as many hold that alcohol has its benefits. (Participant 5)
In addition, the participants believed that the widespread distrust and pessimism of Iranian politicians towards international organisations is one of the obstacles to international cooperation, and senior policy makers often ignore the importance of cooperation in global health. They believed that this distrust was magnified in light of the COVID-19 pandemic.
This belief and mentality among senior decision-makers—that international cooperation is deficient—has been a long-standing issue in Iran. Post-revolution, there has been widespread skepticism toward international organizations, viewed as … organizations serving the interests of major powers. While some of this skepticism may have merit, it is crucial to discern our interests and engage with international discussions while safeguarding the national interests of the Islamic Republic of Iran. (Participant 5)
The appreciation for international health cooperation is low among senior decision-makers. Many from various departments, including the Ministry of Health, either take negotiations lightly or refuse to engage. (Participant 12)
The roots of this lack of faith stem from chronic pessimism and irrational arguments related to international organizations, compounded by the weak understanding and attitudes of our policymakers. (Participant 16)
The participants indicated that one of the most significant challenges to health diplomacy in Iran is the prevailing security mindset that often prioritises political concerns over health.
The predominance of security considerations over other considerations prevents the development of diplomatic interactions in the field of health and adoption of global health standards.(Participant 15)
International factors
Most participants believed that international sanctions have created important challenges for Iran in the field of health diplomacy. They argued that such sanctions harmed Iran’s international relations with other countries and made other countries hesitate to cooperate with Iran. Also, sanctions have adversely affected the economic capacity of this country and have limited access to essential medicines and technologies. As one participant noted:
Sanction means that the country is identified as a threat in the international community. (Participant 8)
The sanctions create significant barriers to engaging fully with global health initiatives. (Participant 15)
Most of the participants stated that institutions such as the WHO and other international health organisations play an important role in health diplomacy in Iran and other countries. They mentioned that these organisations play an essential role in creating standards and basic principles for global health and help different countries improve the performance of their health systems in various ways, such as by providing technical advice.
The World Health Organization tells us that we must adhere to international standards. (Participant 17)
Agenda setting
Interviewees highlighted various domestic and international factors that affect GHD in Iran. Internal priorities include improving public health infrastructure and access to medicines, while external pressures often arise from geopolitical tensions and sanctions. The agenda is set based on urgent health needs identified by the Ministry of Health and other stakeholders in conjunction with international health organisations.
One of the first issues that emerged after 2013 in negotiations between Iran and the West was the supply of medicines and medical equipment. (Participant 2)
Moreover, the importance of aligning health diplomacy with the national interest was emphasised. The agenda often reflects a reactive nature rather than a proactive approach, responding to immediate health crises or pressures from international actors. Some interviewees noted that engaging in international health discussions rarely aligns with comprehensive domestic health strategies.
Without a coherent national strategy, our agenda in global health remains fragmented, reliant on opportunistic interactions. (Participant 14)
A review of interviews and documents indicates that health diplomacy has neither a place in the policy documents of the Islamic Republic of Iran nor a complete definition in a systematic way, which means that it has not been given enough place in the policy agenda.
In the country’s macro policies and strategies, health diplomacy is not addressed. This lack of legal backing has resulted in the absence of a program for integrating health into the policies of other sectors, particularly foreign policy. (Participant16)
Policy formulation
Development of health diplomacy policies is seen as inadequate by some interviewees. While there have been efforts to create strategies, these often lack thorough consideration of collaborative frameworks between the foreign affairs and health ministries. One interviewee described the existing frameworks as ‘ad-hoc solutions’ (Participant 7). For instance, during negotiations concerning vaccine distribution, the absence of a unified health diplomacy strategy was evident, leading to missed opportunities. Additionally, there is a notable lack of investment in training diplomats in global health matters. As one interviewee stressed:
We need a generation of diplomats skilled in health issues to navigate the complexities of international health diplomacy. (Participant 9)
Furthermore, the lack of a cross-sectoral perspective and a comprehensive approach in policy formulation has resulted in fragmented and isolated policymaking in this area. The failure to accurately identify stakeholder groups and their interests, along with the absence of a participatory approach in developing comprehensive strategies and clear roadmaps, has hindered synergy among various organisations and institutions. On the other hand, the failure to identify the country’s comparative advantages, particularly in priority areas for cooperation, and the lack of political will to recognise the capacities and needs of potential partner countries have prevented Iran from effectively capitalising on international opportunities in the health sector. Ultimately, conflicting interests among the organisations involved in this process and idealism in policy formulation are other significant barriers to the successful development of health diplomacy.
Typically, there is no long-term strategy or plan in place, and depending on the emerging domestic or international circumstances, the priorities for cooperation and the countries with which we collaborate may change. We lack sufficient information about the national capacities that we can utilize for the development of health, or which countries possess what resources. Our value positions also influence this process. (Participant 18)
Policy implementation
Some interviewees reflected that effective implementation of health diplomacy policies requires coordination among various government sectors and civil society organisations and challenges in implementation often stem from bureaucratic inefficiencies and gaps in communication between different governmental sectors (eg, health, foreign affairs).
When COVID-19 hit, we had to rely on existing relationships rather than structured diplomacy. (Participant 4)
Furthermore, the health diplomacy that emerged was often fragmented due to the broader political context affecting diplomatic negotiations. This resulted in many health initiatives failing to materialise effectively. The interviewees shared examples of how bureaucratic resistance impeded timely health actions, highlighting that “individual interests often overshadow collective health initiatives” (Participant 3). A call for systematic engagement and clarity on policy implementation procedures was a recurring theme.
Often, we think of public health as fragmented, but it’s essential to view it as a comprehensive area that needs coordinated action. (Participant 13)
Also, the interviewees pointed out that government institutions in Iran operate in an insular manner, and the inadequate coordination between different organisations (such as the Ministry of Health and the Ministry of Foreign Affairs) has prevented the creation of a coherent approach to health diplomacy.
Despite their abilities, the Ministry of Health and the Ministry of Foreign Affairs do not have a proper synergy. (Participant 7)
The Ministry of Foreign Affairs and Health are two responsible institutions, but for the success of health diplomacy, the need for interaction and coordination between these institutions is felt. (Participant 16)
Policy evaluation
Most interviewees asserted that the evaluation of health diplomacy efforts in Iran is rare and typically lacks a workable mechanism and support from relevant stakeholders. They suggested that a structured review process is essential to glean insights from past initiatives, particularly to rectify shortcomings.
We often don’t evaluate the impact of our diplomatic efforts on health outcomes, which is crucial for continuous improvement. (Participant 6)
Without consistent evaluation, we risk repeating failures of the past. (Participant 8)
Explicit mechanisms for measuring the outcomes of health diplomacy are not in place, which undermines accountability. Interviewees expressed a clear desire to establish regular feedback loops to ensure health diplomacy continuously adapts to emerging global health challenges.
The lessons learned from our health diplomacy should inform future strategies. (Participant 6)
Our findings provide some insights about GHD, its main challenges and opportunities in Iran. We realised there is a fragmented and insufficient understanding of GHD that can hinder the effective implementation of related policies. This situation and terminological overlaps and ambiguities complicate efforts to distinguish between concepts such as medical diplomacy, disease diplomacy and international health cooperation. This perspective is aligned with existing literature, which emphasises the need for coherent frameworks in health diplomacy, especially in LMICs.19
The lack of consensus among Iranian stakeholders regarding the definition and significance of health diplomacy highlights the urgent need for a unified conceptual foundation. Recent studies support this view, demonstrating that differing interpretations of health diplomacy can lead to inefficiencies and lost opportunities for international cooperation.1 Additionally, this study shows that ideological and political considerations significantly affect the implementation of health diplomacy in Iran. The unique political identity of the Islamic Republic of Iran both creates opportunities and presents obstacles. As our interviewees indicated, Iran’s Islamic identity fosters a strong potential for cooperation with other Muslim-majority countries,26 but also introduces isolating factors that complicate relations on such issues as LGBTQ+ health, which are viewed differently within Iranian cultural and religious contexts. Therefore, navigating this ideological terrain requires careful planning to maximise the benefits of health diplomacy while minimising conflicts arising from differing cultural perspectives.
Participants noted that health diplomacy is often reactive, addressing crises rather than being embedded as a proactive feature of foreign policy. This finding is consistent with observations made elsewhere regarding the tendency of health policy to be shaped primarily by immediate geopolitical concerns rather than long-term strategies. This aligns with the growing recognition in GHD literature that situational demands often dictate diplomatic engagement.27–29 The COVID-19 pandemic highlighted this reactive stance and served as a wake-up call about the importance of integrating health considerations into foreign policy. However, as expressed by our participants, without forward-looking planning and a strategic framework, health diplomacy risks remaining a fragmented and largely uncoordinated effort.
The findings showed a clear gap between health and foreign policy in Iran. As outlined by our participants, health has not achieved the status of a central focus in foreign policy, often being treated as a secondary concern or a tool to achieve broader diplomatic goals. This perception reflects a pervasive challenge in the global context of health diplomacy, as health issues are frequently used as instruments of soft power rather than substantive goals. For Iran to strengthen its health diplomacy, a shift from this reactive approach to a proactive integration of health into its foreign policy priorities is necessary, enabling the country to view health outcomes as critical to national and international security concerns.
From a policy perspective, this study reveals a significant gap in structured efforts towards health diplomacy. Iranian stakeholders noted the lack of dedicated councils or agencies overseeing health diplomacy initiatives. Respondents emphasised that a coordinated approach led by the Ministries of Health and Medical Education and Foreign Affairs is critical for developing strong health diplomacy strategies. Moreover, health attaches, who are specialised diplomats in health matters, could play a pivotal role in facilitating this coordination and enhancing the effectiveness of health diplomacy initiatives.30 Furthermore, our study highlights the necessity of inter-ministerial collaboration to foster a coherent health diplomacy strategy. Establishing a strategic council composed of stakeholders from both the health and foreign policy sectors, as suggested earlier, provides an opportunity to improve policy coordination and efficiency. This approach not only facilitates a more systematic integration of health considerations into foreign policy but also helps standardise definitions and operational practices among diplomats, health experts and policymakers, thereby creating a common language and understanding for all involved stakeholders.
Our findings also highlight the importance of capacity building in health diplomacy, particularly in training diplomats to understand and negotiate health-related issues. The lack of such skills can lead to missed opportunities and ineffective negotiations, emphasising the need for comprehensive training programmes that encompass both public health and diplomatic skills.18 In this regard, several researches have been conducted to identify the core competencies of health diplomats.30–32
The presence of international sanctions has also been identified as a limiting factor in the context of Iran’s health diplomacy. These sanctions not only disrupt access to vital health resources but also perpetuate an atmosphere of distrust and doubt in global interactions.33–37 A comprehensive understanding of the multifaceted effects of sanctions is critical for developing effective health diplomacy strategies that are resilient to external pressures.
Additionally, cultural factors—especially those rooted in Iranian identity—play an important role in shaping health diplomacy approaches. The interaction between cultural sensitivities and international health norms should be carefully considered. Ignoring these nuances can exacerbate isolation from global health initiatives. Iranian policymakers need to balance these cultural dimensions with pragmatic diplomatic goals and ensure that health diplomacy efforts occur within both local and international contexts.
Finally, our study advocates for a fundamental paradigm shift in how health diplomacy is understood and operationalised in Iran. This requires rethinking health not only as a tool for advancing foreign policy but as an integral aspect of national security and development. The interconnections between health, politics and security indicate that health extends beyond a mere medical issue to become a significant political phenomenon that influences social relations and power dynamics. The health-security nexus highlights two critical articulations: the securitisation of health, which frames health issues as security threats, and the medicalisation of security, which interprets security challenges through a health perspective. These frameworks shape political processes and concepts of statehood, impacting both domestic and international policies.38–40 Historically, health was regarded as a low priority in foreign policy; however, the securitisation of health has rendered this perspective increasingly outdated and insufficient. Furthermore, two decades of research have demonstrated that health is a key driver of economic growth, rather than merely an externality of such growth, positioning it as a ‘high politics’ issue that warrants appropriate attention. A nuanced understanding of health and security as social constructs can inform more effective health policies while also recognising the potential dangers associated with their politicisation.19 41 By institutionalising health within the broader framework of foreign policy, Iran can leverage its capabilities to advocate for global health equity and strengthen its position on the international stage.
To strengthen Iran’s health diplomacy, there is an urgent need for more empirical studies that can lead to the development of a coherent framework. Researchers should examine successful models of health diplomacy from other countries and adapt best practices to Iran’s specific conditions. Additionally, establishing a formal mechanism for the regular evaluation of health diplomacy initiatives will ensure continuous learning and adaptation. This approach aligns with the GHD discourse, which supports iterative processes and emphasises the need for evaluation in health diplomacy to avoid past mistakes.
While this study significantly contributes to the understanding of GHD in Iran, it is not without limitations. It was difficult to engage the policymakers in such a sensitive issue, with some even showing their reluctance to participate. Though efforts were made to foster trust and access to knowledgeable networks, there were problems remembering past policy events and inconsistencies in interviewees’ statements. To cope with these, the researcher has consulted the documents and experts. The qualitative nature of the research means that the findings may not be generalisable beyond the specific context of Iran’s health diplomacy. Furthermore, reliance on expert opinions may inadvertently introduce bias that reflects the interests and shared perspectives of the participants. Future research can address these limitations by including a broader range of stakeholders and employing mixed-method designs to obtain a more nuanced picture of health diplomacy in Iran.
Despite these limitations, this study has several strengths. First, to the best of our knowledge, this study is the first case study that has been comprehensively analysed for health diplomacy policy in Iran, and the findings of this study can be used as a basis for other studies. Its qualitative design enables an in-depth exploration of the complexities surrounding health diplomacy and captures diverse perspectives from stakeholders across various sectors. Additionally, validating the findings through participant feedback enhances the study’s credibility and ensures that the insights generated resonate with those directly involved in health diplomacy.
Table 2 presents some of the policy recommendations and related actions for GHD in Iran. The policy recommendations for GHD in Iran emphasise developing a comprehensive operational framework, shifting to proactive health integration in foreign policy, establishing a governing body, training diplomats, mitigating sanctions impacts and ensuring continuous evaluation for accountability. Implementing these actions will strengthen both internal health diplomacy and contributions to global health security.
Policy recommendations and actions for GHD in Iran
An incoherent and somewhat contradictory understanding of health diplomacy might have hindered effective policymaking and international cooperation to improve population health in Iran. Furthermore, integrating health considerations into broader foreign policy agendas is essential to promote national interests and global health outcomes. We advocate the redefinition and institutionalisation of GHD as a proactive strategy to facilitate the pathway towards sustainable health development in Iran. GHD offers a pathway to addressing not only several health-related global challenges but also many other areas of global concern through the coming together of countries and organisations to produce more integrated, aligned efforts for the Sustainable Development Goals (SDGs). That means building partnerships based on priorities in human development and promoting peace. Ultimately, universal health coverage and the SDGs depend on responses to the global social determinants.
Competing interests: None declared.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review: Not commissioned; externally peer reviewed.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Not applicable.
This study involves human participants. The Research Ethics Committee at Tehran University of Medical Sciences (TUMS) approved this study (IR.TUMS.SPH.REC.1397.157). Participants received an oral overview of the research’s nature and objectives. They were provided with detailed information and consent forms before the interviews and were informed of their right to withdraw from the research at any stage. To observe confidentiality, we ensured the anonymity of all identifying information regarding participants and made research results available to participants on their request.
Acknowledgements
This work is part of a PhD thesis in health policy approved by the Tehran University of Medical Sciences, Tehran, Iran.
