Factors Affecting Health Policies for Older People in Iran

ABSTRACT Globally, the number and proportion of people aged 60 years and older is growing fast. As people age, health needs become more complex, and the health system’s responsiveness to older people’s needs requires evidence-informed policies. Hence, this study explores the factors affecting the health policy development process for older people in Iran. We conducted 32 interviewers with people aged 60 years and older and 21 interviews with key informants involved in policy making related to older people. Qualitative data were analyzed using thematic analysis. Actors and stakeholders, policy structure, selected health policy processes, the health care service delivery system, government financial support, and community and culture building are the most influential factors in health policy making for older people. Government policies and health priority interventions are needed to address these influential factors for older people to ensure healthy aging over the life course.


Introduction
Aging is an emerging global phenomenon.Nearly most countries in the world are experiencing growth in both the size and the proportion of older people in the population.The suggested term for people 60 years and older is "older people" (Kowal et al., 2010).Estimates suggest that in 2018, globally, persons aged 65 or above outnumbered children under five.By 2050, one in six people in the world will be aged over age 65 (16%), an increase from one in 11 in 2019 (9%) (UN, 2019).The number of persons aged 80 years or over is projected to triple to 426 million by 2050.With aging, health needs become more complex, and the growing burden of chronic diseases would eventually affect their quality of life and well-being, posing a significant public health challenge.The utilization of health and long-term care services during the aging period is considerable.
A considerable increase in older people's share influences social and economic systems in different societies (Bloom et al., 2011).Hence, the health system's responsiveness to older people's needs requires tailored evidenceinformed health policies (Meng et al., 2011).Promoting life-long learning and expanding assisted living and age-friendly communities, preventing abuse and violence against older persons, addressing discrimination against older persons at work, and creating schemes for long-term and institutional care are among the policy responses adopted by governments of some countries.
Given current demographic trends with increasing longevity, the need for appropriate preventive and therapeutic interventions and working health systems strategies that keep and ensure the health and well-being of all older people, current and future, becomes even more pressing (Economic & Division, 2010).Being a global phenomenon, aging occurs fastest in low and middle-income countries (LMICs), home to over 83% of the world's population.Since many of the fastest-growing populations are in the poorest countries, there is even less time for making policy and planning to ensure that no one is left behind (Economic & Division, 2010;Kalache et al., 2005).Evidence suggests various barriers can prevent older people from accessing needed health care services.Among them are ageism, age discrimination in resource allocation, a lack of age-appropriate health services, incomplete insurance coverage, and insufficient means to cover the high costs of chronic disease management (Mobasseri et al., 2020;Prince et al., 2015).These and other potential barriers must be considered when developing and revising health systems' policies (Albanese et al., 2011;Roy & Chaudhuri, 2008).

Context of Iran
Like most countries, Iran has been on the path of population aging due to decreased fertility, lower mortality rates, and increased life expectancy (Doshmangir et al. 2023).According to the World Health Organization (WHO), Iran is one of the three countries with the most rapid demographic changes.Together with Chile and China, it will soon have a more significant proportion of older people than the USA (WHO, 2012).Between 1966 and 2016, the aging index in Iran increased from 13.8% to 38.6%.In 2022 (The World Bank Population growth (annual %)-Iran, Islamic rep 2022), the proportion of older people(over 60 years) in Iran exceeded 10% of the total population.Moreover, the share of older people is expected to rise during the next 30 years up to 25%, making it the fastest-growing population demographic group in the country (Mehri et al., 2020).
Culturally, there is a positive view of older people in Iran, and Iranian culture does not easily allow children to leave their parents in nursing homes (Hajinejad et al., 2019).In most Iranian households, older people are privileged by a high position and supported by family members (Tajvar et al., 2008); Increased longevity is a positive trend and can be attributed to improvement in the overall standards of living and advancements in primary health care and medical services (Beyrami et al., 2019;Doshmangir et al., 2020).However, increased longevity might significantly strain health care services provided without a necessary legislative base and timely budget planning and considerations adjustment.The demand for health care services for older people is eventually expected to rise due to the shift in disease burden, mainly driven, but not exclusively, by diminishing health, frailty, multiple long-term conditions, complex comorbidities, and common conditions such as falls, incontinence, immobility, and dementia (Chiou & Chen, 2009WHO, 2004).Hence, Iran needs to adopt new policies to tackle possible challenges, create opportunities for the growing older population, and ensure adequate geriatric and gerontological capacity among the health and social care workforce (Doshmangir et al., 2023;Abbasian & Shaghaghi, 2020).Identifying factors affecting health policies for older people is a required priority to design, formulate and implement sound policies on population aging.This study explores the factors affecting health-related policy making related to older people in Iran.We hope that results can significantly improve the well-being, health, and social care service coverage of older people.

Study design
This qualitative study used two primary data sources: face-to-face interviewing key informants, focus group discussions and reviewing national policy documents related to health policy development about older people in Iran.The study was conducted between October 2019 and July 2020.

Sampling and data collection
We first conducted scoping document review to select relevant documents.Document analysis helped us better understand the policy development process, find out transitions in priorities and related policy content throughout the years, follow policy change trends over time, observe how policy issues were framed and how information was presented formally (Dalglish et al., 2020).We reviewed and evaluated national policy documents related to health policy development for older people in Iran (e.g., national programs for older people and national health plans for older people).
The key documents and policies were identified after searching the websites, such as Iran's parliament research center, public health deputy of MoHME, treatment deputy of MoHME and Iran health insurance and consulting key informants and specialists working in the field.Whenever electronic versions of the related policy documents were unavailable, the researchers contacted the relevant organizations in-person and requested hard copies of the documents.In total, 32 relevant policy documents were reviewed.To supplement the scoping document review, we conducted semi-structured interviews (final interview guide SupplementaryTable 1) and focus group discussions (final version in SupplementaryTable 2) with 53 individuals.Four other individuals declined to participate.
Semi-structured interviews were conducted via the Internet (i.e., Skype), over the phone, or face-to-face, depending on the participant's preference.More specifically, two members of the research team (AAT and LD) conducted 32 face-to-face semi-structured interviewers with older people (respondents' characteristics in Supplementary Table 3).21 interviews with key informants involved in policy making related to older people were conducted using various engagement modes as described above (respondents' characteristics in Supplementary Table 4).Respondents were recruited using purposive and snowball sampling to ensure selected respondents represented different groups.The inclusion criteria for recruiting older people were being a citizen, defined as being active or participating in social or cultural communities, rituals or councils related to older people, having information about government or health system policies related to older people, participating in local and national policies related to older people's health.The inclusion criteria for health policymakers and planners were work experience in formulating and implementing policies related to older people in the country or knowledge from previous experience.Four additional experts in the field of older people health and policy making reviewed and assessed the validity of the preliminary interview guide.
The interview guide was revised following the pilot interviews with two experts and three older people.At the beginning of the meeting, a brief explanation of the study aim, the data collection process, and the role of researchers and participants in the study was provided.Only consenting participants were invited to take part in the study.Each interview lasted between 50 to 80 minutes.Each focus group discussion lasted, on average, between two to three hours.The focus group discussion guide consisted of seven main questions.Factors affecting health policies for older people in Iran were among the central questions.The conversations were digitally recorded, transcribed verbatim, coded, and categorized with the interviewee's consent.

Data analysis
We applied an inductive approach to analyze semi-structured interviews and documents to identify key concepts.This approach was used to categorize verbal data based on themes that emerged from the crude data.Interview data were reduced and structured using content analysis (Elo & Kyngäs, 2008), an aptly suited technique for applied policy research.Inductive content analysis is suited for research with little to no prior studies related to the research question (Thomas, 2006).The READ approach and its four main steps (reading materials, extracting data, analyzing data, and distilling findings) were used to document analysis (Dalglish et al., 2020).Data analyses were conducted during the collection process.First, the researchers (LD and AA) immersed themselves in the data by listening to audio recordings, reading the transcripts and reviewing field notes.The researchers identified key ideas and recurrent themes throughout this process and noted them.Then, the thematic framework was identified through the notes taken during the familiarization stage and the a priori issues.The developed framework was used to filter and classify the data.In the next stage, portions or sections of the qualitative data that correspond to the particular theme were identified.MAXQDA 12, as a qualitative data analysis tool, was used to index references and annotate in the margin beside the text.In the fourth stage, the specific pieces of data indexed in the previous stages were arranged in charts of the themes.In the final stage, the key characteristics, as laid out in the charts, were analyzed and guided the researchers in mapping and interpreting the data.

Results
Based on the document review and semi-structured and focus groups interviews results, five main themes and 13 sub-themes were identified.The main themes included: actors and stakeholders, policy structure and process, financial support, services delivery structure, and community and culture building (Table 1).

Stakeholder multiplicity
Respondents believed that the Iranian Ministry of Health and Medical Education (MoHME) is the primary custodian of community health in policy making, particularly concerning older people's health.The most critical stakeholders in this field are organizations and groups such as the State Welfare Organization (SWO) and Ministry of Cooperatives Labor and Social Welfare (MCLS), non-governmental organizations, charities, health service providers, international organizations, and medical professionals.Most interviewees believed that stakeholders' role and power and their support in implementing older people's health policies would help achieve the goals of the designed policies.However, MoHME could not manage this issue alone.MoHME does not have the needed facilities to provide necessary support and rehabilitation services to older people, and the welfare organizations were deemed most suited for their provision.Based on legal documents, others consider the National Council of the Older People to have a more prominent role and think that this organization is the central policymaker in the affairs related to older people.
In the Fifth Plan and the new policies of the integrated health system, the Ministry of Health is in charge of health.However, the important thing is that health is a social issue.Many of its dimensions, such as the environment, social welfare and livelihood and retirement, are not subdivided by the Ministry of Health, and these challenges unfortunately exist.(Senior MoHME policy maker)

The conflict between multiple stakeholder roles
Interviewees also noted conflicting roles and existing overlaps between the MoHME and the MCLS and SWO, which are part of the MoHME.Following the existing legislature, the responsibility for disabled persons is with the SWO, and the responsibility for public health issues is with the MoHME, which causes conflicts.
The main responsibility has not been determined -the legislator has given the responsibility for disabled people to the State Welfare Organization and the responsibility for people's health to the Ministry of Health and Medical Education.Therefore, we can say that the health policies of the older people are partly related to the Ministry of Health and Medical Education and partly related to the state Welfare Organization, which in itself is a problem.(SWO policy maker) The SWO and the MoHME often confront each other in matters related to the health of older people.At the same time, interviewees scored the health status of the older people in the structure of the MoHME as "weak."Extensive structural changes, separation of the SWO from the MoHME and the health policy-making process related to older people have significantly impacted past policies and how they were implemented.
Unfortunately, with the very heterogeneous integration that has taken place in previous governments and the merging of three heterogeneous areas such as cooperation, labour and social welfare, and the formation of a ministry, the current situation of the welfare organisation and social activities has worsened.(Faculty member) Ageing health policies are developed mainly by political and technical elites, politicians, specialists and physicians.Respondents believed that older people have no representation or power to influence decision-making and policy development, and people from other age groups prepared policies concerning older people.There is also no specific forum or channel that would enable older people to participate in policy-making.
Older people are a group that, for various reasons, do not have a tribune and cannot defend their rights.(Older person) But really, one of the problems for the older people in many countries is that they do not have a voice, which causes their social isolation, and it causes the rights of the older people to be violated.(Older person)

The role and capacity of mediators
According to the interviewees, only a small number of charities are active in the field of older people's health.They have a minimal role in developing policies related to older people.However, they have the potential to play a mediating role between policymakers and older people.For example, one of the oldest charitable associations is the Kahrizak Older People Complex, which has provided services to poor older people for decades.Another example is the non-governmental organization, the Dementia and Alzheimer's Association of Iran, which works with older people's health.The private sector's role is mainly in establishing and managing older people's nursing homes and residential complexes.They do not play an active role or influence the policy-making process.Overall, non-governmental organizations' capacity to intervene in health policy making is insufficient, and even the existing capacity is underutilized.Furthermore, these organizations must be empowered to work better.According to the interviewees, the media in Iran can also play an essential role in health policy making and bringing issues to the policy agenda.However, this capacity has not been used, and even the media is unaware of the importance of older people's issues.
The media is more focused on specific issues and issues where money is involved, and the voices of older people are not being heard.(MoHME officer)

Health insurance coverage
Despite some specific policies in some areas of health for older people, the Iranian MoHME does not have a specific action plan and has neglected related policies.In Iran, basic and social insurance does not cover all health-related costs and requires supplementary insurance.There is no special insurance for the elderly that covers long-term care costs.For example, parallel to Medicare and Medicaid in the United States of America or Elder Shield in Singapore, there is no insurance in Iran.The current insurance coverage does not include social health services and home health services, so it is challenging to appoint a home nurse and pay for it.Respondents believed that the comprehensive welfare and social security system does not adequately protect older people.Their views are usually unidimensional, and there is no adequate insurance for older people.
The older people are retiring, but their pensions are inadequate.It is essential to link older people's health policies to welfare policies.Do our policies respond to access to affordable food and fruit?The cost of fruit and preparing proper food are high.When we plan, we usually look at and move one dimension forward.Only one dimension usually dominates our minds.(Health insurance officer) Most interviewees stated that the existing insurance programs do not have a specific plan for older people, geriatric services, and common diseases of older age.The insurance coverage content is identical for older people and other age groups.Supplementary insurance for older people is available only in a few business structures.It would be available for all citizens, although its cost wavers according to various options.Financial accessibility is limited, and not all seniors can utilize insurance benefits.
. ..Insurance companies remove deceased people from the list and invalidate their insurance books so that no one can deceive them.The older people must go to the insurance office to prove they are still alive.What does it mean for older people if they are disabled?(Older person)

Planning for long-term care
According to the interviewees, the MoHME has not paid enough attention to aging and lacks a long-term strategy or vision.They also stated that healthy and active aging programs and policies should start early to maintain continuity in old age.Inadequate coherence between upstream and downstream policies and a lack of communication between existing policies have resulted in a lack of specific interventions or service packages for older people.Existing policies and programs are often passive, short-term, cross-cutting, and lack a holistic and macro perspective.
The policy of forming the National Council of the Older People, formulated and approved in 2004, had an appropriate and coherent content and was accepted by the parliament in its time.However, for some reasons, this policy was not implemented properly.(Senior policymaker) We have not done anything about older people's mental health problems and depression.Families of older people should be educated about the specific characteristics of older people and their needs.(SWO officer)

Policy and program monitoring
Interviewees noted that indicators and tools for evaluating these policies and existing programs are not found in the existing policies' content.They also stated that there is no strict assessment of the quantity and quality of programs implemented, such as the integrated aging program.
So far, not only have we not evaluated the policy; we do not even have a way to measure the scale of a problem in this field.(Senior MoHME officer)

Intra-and inter-sectoral collaboration
However, participants also noted some positive aspects in the field of health of older people.Such aspects include the sensitization between the state officials and academic institutions on issues related to the aging population, training medical students in various fields of aging, establishing a geriatric office in the MoHME, and the existence of clinical expertise to cover services for older people.
Experts say that most of older people's health issues are outside the scope of the MoHME, and there is a need for solid inter-sectoral leadership and intrasectoral governance.At the same time, there are very few capable people in the MoHME, and there is serious concern about governance and leadership.Also, the implementation of policies in the country follows the top-down approach, and policymakers formulate and announce policies that must be implemented in any way possible.This top-down attitude prevents the formation of social participation.
We usually formulate and approve a policy and then force it to be implemented.(Health policy maker) Other inhibiting factors considered by the participants in the study included intra-and inter-sectoral inconsistencies, the inability of the MoHME to externally influence other sectors involved in the health of older people, lack of consideration to the issues of aging and insufficient attention of policymakers and politicians to the aging society, lack of the multiplicity programs in the health sector, the inability and inefficiency of the structure of the health network and family physician to implement the announced policies and programs.
The most important difficulty in the health of older people is that the Ministry of Health and the health system have the least role in the health of older people.Everything we want to do about the health of older people is faced with the external sector, and we do not have the tools to manage and examine the external health sector, which is our biggest problem.(MoHME officer)

Financial support
The policy response to the financial situation of the older adults Interviewees believe that the high cost of health care for older people has attracted politicians' and policymakers' attention, and they have developed and implemented programs and policies in this area.Other interviewees cited the economic hardships of older people as a source of influence on older people's policies and health.Inadequate pensions and the poor economic state of most of older people were among the issues raised by the vast majority of interviewees.
8% of the population are older people, and 27% of health care costs are being spent on them.(MoHME, Health policy document).
One-third of older people population will have difficulty surviving if no one pays them.Economic problems contribute too many of the problems in older people.(SWO, Health policy document) According to the interviewees, chronic diseases and associated high treatment costs also strongly affect older people's economic situation and insurance organizations.Moreover, Iran's current economic situation, international sanctions, and high inflation also adversely affect policies.

Budget allocation
Interviewees consider the annual budget, expenditure of the health sector, and financing potentially effective in formulating and implementing programs and policies for older people's health.They believe that the budgets allocated to these issues are insufficient, and the lack of financial resources does not usually allow for any long-term policy-making.The MoHME spends all its efforts on solving urgent problems and matters.

Budgets allocated to older people's health are minimal and distributed among different organisations. Unfortunately, the allocation of budgets at the national level and especially within the Ministry of Health does not correspond to the older people's needs. (NGO for the Welfare of Older People)
The independence of the SWO causes the country's budget for older people's health to be divided.A large budget is given to the SWO, while the MoHME has no role in policy-making.
The budget of the State Welfare Organization and its independence in practice on the one hand, and the minimal share of the Ministry of Health in the budget for the older people on the other hand, actually reduces the leadership role of the Ministry of Health in policymaking, management, implementation, monitoring and evaluation of older people.(SWO officer) The main form of primary health care in Iran is the care of mothers and children.Priority is still given to other age groups in the past and now.Resources and budgets are mainly devoted to children and youth health programs.Recently, chronic disease care has been added and defined for the entire population, and there is no unique program for seniors.Although the integrated geriatric care program is implemented in health centers, the quantity and quality of the program are debatable.
In terms of resources and budget in society, more attention is paid to young people and children.There is no more positive view of older people and older age in society.Moreover, some say that they have lived their lives, and it is not rational for them to spend resources on them.(Older person)

The impact of the cultural context
Several interviewees believed that due to Iran's religious context, religious and cultural factors can play an important role in policy making for older people by emphasizing respect.However, they acknowledged that attention to these factors was more rhetorical, and one of the main problems in the issue of older people is the cultural problem in society.
"In our culture, there is more emphasis on respect for older people, which is done in words, but in practice, it seems there is no practical action." ."We have to use religious factors.Clergy and mosques are places that I think are influential in social and behavioural leadership."(Older person) Interviewees believe that social factors have been less influential in older people's health policy making, but more attention has been paid to this issue.

Strategies adopted to deal with ageism
It was stated that there is ageism in Iranian society, which is an influential social factor.However, some interviewees mentioned that adopting a legal article in the Seventh Development Plan and awareness of the issue of aging in the country and public opinion had been an appropriate way to bring the attention of policymakers and government officials to issues of older people.
Due to the ageing population in Iran and the challenges ahead, including ageism, the necessary forecast should be made, and related content should be included in the seventh development plan.(Health researcher)

Delivering integrated care
Experts said there is no comprehensive system for providing proactive health services for older people, especially in the cities.This issue has been abandoned, and all services are inactive.They stated that the primary health care system is incomplete.Prevention, treatment, and rehabilitation services for older people are not included.In the current framework, providing appropriate services to older people is impossible.There is a need to create new templates and capacities for such services.Experts participating in the study expressed different views on the problems of providing health services to older people.Some emphasized the different abilities of the SWO and the MoHME in services provided to older people and believed that the SWO is active and capable of providing support and rehabilitation services but cannot provide acute medical services.The MoHME is active in the acute treatment of patients, but follow-up treatment of older people has been practically abandoned.
The State welfare organisation does not have the capacity and facilities to cover all aspects.The work was suspended and was not completed.However, in my opinion, the Ministry of Health, which has an excellent capacity but does not have a sanatorium, is also weak in rehabilitation.These areas have not been developed in the Ministry of Health.The Ministry of Health pays full attention to acute care and does not pay attention to the individual after treatment and discharge from the hospital.After-hospital care is very important for older people.(Health researcher)

Age discrimination in service delivery
The interviewees acknowledged that the country's health care networks had not received the necessary training to prevent and provide primary health services to older people, especially for chronic diseases and mental illnesses.Most importantly, there are no facilities to provide the desired service to older people in the country's health network.The country's health care network had been designed and implemented to maintain and promote the health of the mother and children.Therefore, introducing the provision of services for older people in health centers is associated with resistance.The lack of necessary facilities and workforce has caused the inefficiency of these services in the network.
The system and structure we have to provide services is an ancient system and is designed to provide limited services to mother and child, and if we want to put the heavy task of providing basic health services to older people in this system, this structure will not be able to do it, and we need to change the structure of health centres.(National document for older people) The nature of the problems of older people is different from other age groups.It was stated that a package of treatment and prevention services provided by the MoHME should consider other sectors.
The nature of ageing problems is different from other age groups.With increasing age, physical strength decreases.We try to maintain other dimensions of health in older people, which is possible.(National document for older people) The lack of specialized structures to provide services to older people in the country, such as specialized hospitals or medical wards or clinics, was one of the interviewees' points of interest, significantly affecting the older people's health policies.
Why should not ageing people, which make up a large part of the country's population, have its special hospitals?Unfortunately, we do not have geriatric hospitals in our health system.(Health care provider) Another critical problem in providing health services to MoHME is their access to services.Many older people cannot leave their homes and are denied access to health care.". ... Some older people have no job and do not have the physical ability to leave home.What are our plans for these people who cannot leave home, so if we want to talk about health and medical needs?We think there are many problems with physical access."(Public health officer)

Discussion
We identified five factors influencing older people's health and social care policy making.These factors include actors and stakeholders, health policy structure and process, healthcare service delivery system, government financial support, and community and culture building.

Community and cultural awareness
As an influential background factor, cultural and religious factors play a significant role in the country's decisions and policies (Buse et al., 2012).These factors have also been influential in older people's health, but attention to these factors is more of a slogan.In practice, proportionate attention has not been paid to older people's health (Ghavarskhar et al., 2018).Our study shows that religious components, especially the clergy, are not appropriately used in policymaking for older people.This underlying factor plays a significant role in implementing policies and achieving health goals in Iran.Studies in several developing countries also showed the significant role of religious clerics and tribal leaders in policy policymaking, success, or failure (Agyepong et al., 2012;Khan et al., 2018;Khodayari-Zarnaq et al., 2017).

Actors and stakeholders
According to our study's findings, the conflict of interest between individuals and specialized departments seriously affects policy.At the same time, managers' short period of responsibility and management instability also causes haste in decision-making and policy making, ultimately weakening the policymaking system.In analyzing the role of policy actors, it should be noted that stakeholders' role and power and their support for the implementation of health policies for older people will lead to achieving the objectives of the designed policies (Siddiqi et al., 2004).The results of our study show that in the health policies of older people, the strongest beneficiary and the principal trustee is the MoHME.However, MoHME alone cannot cope with this because it lacks the necessary facilities for older people, such as support services and rehabilitation clinics.Instead, the SWO is more capable in this field.Social Security Organization, Iran Health Insurance and National Pension Organization are the role models whose behavior and policies directly affect the health of older people and related policies.These institutions and organizations have less power than they need, but they are the primary role models in shaping the health behaviors of older people.
Studies have reported no integrated governance in the policy making for older people in Iran (Nayeri et al., 2018;Safdari et al., 2016).The contradictions between the MoHME and the SWO in Iran (Goharinezhad et al., 2016b), the absence of a specific structure for the health of older people (Safdari et al., 2016), inactivity of the National Council for older people (Firoozeh et al., 2009), and the existence of parallel and nonprofessional organizations (Goharinezhad et al., 2016a) were among issues mentioned in studies.Other studies have stressed poor inter-sectoral cooperation between key stakeholders (Firoozeh et al., 2009;Goharinezhad et al., 2016aGoharinezhad et al., , 2016b;;Safdari et al., 2016).Some other studies argued that poor policies exist because of the absence of general health-based policies, strategic orientation in aging health programs, and preference for treatment over prevention (Goharinezhad et al., 2016a;Yahyavi Dizaj et al., 2018).Another important influencing factor in the health policy making that we achieved is the influence of the media.Another study conducted in Iran also showed that social media, such as Twitter, played a crucial role in health policymaking, especially during the COVID-19 pandemic in Iran (Ghasemyani & Khodayari-Zarnaq, 2021).

Service delivery system
Services provided to older people in Iran are poorly organized and face challenges such as the lack of specialized older people clinics and hospitals, accumulation of facilities in metropolises, absence of older people friendly centers, lack of a dedicated queue and priority for older people treatment in hospitals, lack of links between different levels of prevention to rehabilitation, absence of palliative and end-of-life care, lack of attention to annual checkups and overall poor quality of care in care homes and day-care centers (Goharinezhad et al., 2016a(Goharinezhad et al., , 2016b;;Mahdizadeh & Solhi, 2018;Nayeri et al., 2018).
The current structure of health care centers in the first level of services and prevention is a structure established in the past to provide outpatient and prevention services, primarily for maternal and child health.It needs to be updated regarding structure, human resources, and facilities (Agyepong et al., 2012).This study shows that to provide necessary health services to older people, medical universities at the provincial and regional levels should reexamine the health care delivery system and establish necessary services and structures.Research in other countries also emphasizes that the first step in policy making for the health of older people is the evaluation and revision of the provision of existing services and the current functioning of health systems at the national, provincial, and regional levels (Chappell & Hollander, 2011).
One of the upcoming challenges for implementing preventive and support programs for the elderly is the COVID-19 epidemic.Some articles have addressed this issue and provided solutions.One of the existing solutions is promoting e-health to reduce costs and increase the effectiveness of remote rehabilitation or remote self-care training (Shahali et al., 2020).Identifying and screening older people with mental problems at the community level and using communication technologies to reduce mental problems such as stress and depression, especially during the COVID-19 pandemic, can lead to mental wellbeing (Doshmangir et al. 2022;Peyman & Olyani, 2020).Innovations to maintain the physical activity of the elderly without physical contact with community members can help prevent the spread of Covid-19, such as providing an elder-friendly and safe environment for activities such as outdoor cycling.Other studies also confirm the findings of our study.A study showed that the inequality in spatial access to health services affects the vulnerable sections of society, namely the elderly, women and children (Reshadat et al., 2019).Therefore, providing alternative solutions and adapting urban spaces for better access should be on the agenda (Shaer & Haghshenas, 2021).
The population of older people as the target community has no power in decision-making and policy making, and policymakers do not hear their voices.Usually, other age groups make policies for them.The WHO states that in its efforts to promote health services for older people, health policymakers and planners often neglect to ask older people about their problems in health care and community-based care centers and call for ideas for change.Both users of the services and its providers, such as physicians, nurses, and other health care workers, are not asked about changes needed for improvement (World Health Organization, 2012).In 2006, WHO launched an agefriendly city and community initiative, driving local cities and communities to foster and support active and healthy aging (WHO, 2007).Although Iran implemented an age-friendly cities project in some cities, it did not ultimately achieve all identified goals (Heidari et al., 2021;Izanloo et al., 2021).

Financial support
The system and economic factors, budgets, and financing of health services have not had much effect on the health policies of older people, in the sense that when formulating policies, little attention has been paid to the available budgets and resources.Considering the minimal budget for older people's health, the formulation of idealistic policies, and the setting of ambitious goals in most existing policies, it is clear that these factors have not been considered in formulating policies.Research shows that the effect of population aging on health care costs is much more significant than previously thought (Shojaei et al., 2019;Srivarathan et al., 2019).Therefore, new policies should seriously consider financing health services for older people.
Studies show that society fully supports older people in most European Union countries and provides complete health services.A review of the policies and programs of developed countries shows that retirees are fully covered by social protection and comprehensive health insurance in most European countries.In some of these countries, all residents and citizens (including older people) are eligible for full social and welfare support.However, most studies have reported that increasing poverty and economic dependency in older people reduces their economic access to health care and increases their exposure to devastating health costs (Firoozeh et al., 2009;Goharinezhad et al., 2016b;Yahyavi Dizaj et al., 2018).Other studies reported that older people's health insurance could be inappropriate due to inadequate coverage of services, such as rehabilitation services, and the inability of insurance policies to prevent the likelihood of households enduring frustrating out-of-pocket costs (Goharinezhad et al., 2016a;Nayeri et al., 2018;Safdari et al., 2016;Yahyavi Dizaj et al., 2018).

Policy structure and process
Overall, our results suggest that currently, there is a lack of specialized programs and policies by the MoHME that would address older people's health needs.Therefore, logical coherence and strategic orientation are not observed in the inter-sectoral communication between health sectors, which operates as two deputies of Ministry of Health.Our study shows that units have been established at different times to coordinate policies that have changed over time.There is practically no coordination between the majority of existing programs and policy packages, which shows the weak policymaking capacity in the past MoHME.Numerous changes in the policymaking structure and organizations in charge of older people caused the policy-making process regarding the health and welfare of older people to undergo fundamental changes.Formation of a new Ministry of Welfare, the merger of the Ministry of Welfare with the Ministry of Labor and Social Security, followed by the heterogeneous merger of the Ministry of Welfare and Social Security with the Ministry of Cooperatives, and the subsequent formation of the Ministry of Cooperatives, Labor and Social Welfare -all affected policy making in social affairs, especially in the field of health and welfare of older people.
Moreover, severe damage has been done to the policy-making structure regarding the health and well-being of older people.The frequent change of rule-makers in policy-making and structural change and the separation of the Welfare Organization from the MoHME and its continuation of activities under the Ministry of Welfare caused matters related to the health of older people to be left out of view by senior policymakers.The results of our study reiterated the necessity to account for international experience, successful international policies and paradigms, and the international community's recommendations when formulating national and local policies.
According to the WHO, one of the policy-making problems in developing countries is the lack of attention to all components and stakeholders in policy making (WHO, 2000).Studies showed that stakeholders' role in well-organized structures in developed countries is more prominent in policy making.Also, policy-making processes have formal and specific procedures and steps in these countries and are institutionalized in democratic systems.While in developing countries, the policy-making process is different; in many cases, policies are based on the specific relationship and interaction between policymakers and executives may have different policy outcomes (Khan et al., 2018).According to the country's upstream laws, the MoHME is responsible for identifying problems, preparing agendas, and approving health policies.Usually, experts and employees of different ministry departments know health problems and issues in the community, prepare and formulate solutions, and present them to the ministry's senior officials.At the national level, policy decisions on health policies have been made centrally in the MoHME.Some policies have been submitted to the Islamic Consultative Assembly, the government or the High Council for Health and Food Safety for legalization.Of course, the Islamic Consultative Assembly also has authority in policy making and adopting laws for all sectors in the country.Our research shows that in policy making for the health of older people, their problems and specific characteristics have not been carefully and adequately considered.Our findings show that this issue has not been adequately studied in the past.If it had been properly examined, it would have led to adopting a policy and the formation of the National Council of the Older People, which should have continued.Overall, health systems are complex interactive systems (Roberts et al., 2003), where planning and policy making in this system and all organizations require system thinking and a comprehensive view.This approach requires an in-depth understanding of the connections, interactions, and behaviors among the system's components that make up the entire system.In the health system, system thinking focuses on the relationships between the system's components, the synergy created between the components resulting from these relationships and the events that occur in the system (De Savigny & Adam, 2009).According to the theory of systems thinking, everything is related to something else.Hence, implementing a reform or changing a policy is complex, so it is challenging to predict health care system outcomes with certainty (Agyepong et al., 2012).

Limitations and strengths
We acknowledge some limitations of this study.For example, we did not always have adequate access to all main policy actors and some documents related to policies for older people, which may have led to the loss of some critical information.The authors tried to overcome this limitation by interviewing a variety of key informants.Despite the limitations of this study, the findings have helpful, practical implications.This study allowed older adults to discuss policy making issues among themselves and show the importance of their participation to policymakers.Also, the results of this study can provide a way for policymakers to identify the factors influencing the policies of older people and make evidence-informed decisions in this area.To increase the study's validity, we included key informants with sufficient experience in the field of the study.Also, the high level of researcher involvement in all stages of the study and the allocation of sufficient time increased the conformability of our study.In order to increase the dependency, we considered all of the comments mentioned by the research team members.The results of the data analysis were presented to some participants, and we accounted for their feedback when completing data analyses.Data collection and analysis were performed simultaneously.

Table 1 .
Themes and subthemes related to factors affecting health policies for older people in Iran.