We carried out a relatively comprehensive study in Iran involving many stakeholders in our in-depth interviews and desk reviews of the published and unpublished documents. Iran HRS challenges are primarily in stewardship and governance like many other developing countries (11, 32). Even though integrated and coordinated stewardship in any health-related system and sub-system, like HRS, is the start point for efficient reforms (33). Iran has started a progressive path in health research, but many works remain to do. In this study, we tried to have a practical approach in determining the issues and recommendations and preparing a base for further studies and interventions. Most importantly, improving the leadership and setting a vision with the stakeholder's consensus provides the base for other sub-functions enhancement like priority setting. Dealing with the structural and legislation challenges also works in another aspect. Setting a monitoring and evaluation (M&E) mechanism and communication and networking among key stakeholders in all three Mac, Mes, and Mic levels are also recommended. All thematic challenges make sense in all three groups (Mac, Mes, and Mic), but some need special attention in the specific levels discussed below.
4.1. HRS challenges in Macro level
The first top challenge at this level is national health research leadership. Others with high importance degrees are structure, legislation, and using evidence in decision making. The leadership-related challenges are not limited to HRS or Iran. Health leadership is an international issue (34, 35) in all development levels of countries (34–36) and different scales and sub-systems of the health sector, like hospitals (37), the medical education system (38), and Iran HRS (38–42). Specifically for Iran HRS, the leadership challenges are mainly due to the multiple stakeholders and inconsistency in their policies (24, 43). At the same time, leadership is also a matter of future human resources management from different aspects (25, 42–44). Establishing a focal point to institute the NHRS governance/management is recommended dealing with such challenges (45–48) so that defining a comprehensive perspective and following strategic plans make sense and work (24, 49).
Next is the structural issues of Iran's HRS: political dominance, conflict of interest management, centralization, bureaucracy, and unsustainability and non-agility of the HRS. The authority of power and policies is a global public health issue (50). The particular context is also effective in how the dominance affects the HRS. Changing the government (by changing the president every four years) also changes the HRS in Iran (51–54), making the structure unsustainable. High bureaucracy (42) and centralization of HRS (21, 39, 51) are structural challenges intensified by policy dominance that all make the HRS not being agile as it is supposed to be. Conflict of interest is a hidden driving force that reduces the research policy connectivity in health systems (55). The complex inherent nature of health systems makes it challenging to manage the COI in most countries (55, 56). There was less evidence directly about the status of COI in Iran HRS, but it was the concern of policymakers and research bodies. The main types of COI affecting HRS are policymakers' dual or multiple roles, the financial interest of research bodies, and political interests (55). Enhancing the regulation and monitoring mechanisms and adopting a proactive approach in managing COI are the leading solutions (55, 56).
The third is laws and legislation that are the initial basis in the health sector and its underlying sub-systems on a national and international scale. Global health law is a concept that underlines setting legal norms, processes, and institutions worldwide that apply to all actors ("consisting of organizations, governments, businesses, foundations, the media, civil society, and charities"). One of the main functions of global health law is to stimulate investment in research and development, mobilize resources, set priorities, coordinate activities, monitor progress, create incentives, enforce standards and research (new vaccines, pharmaceuticals, and technologies. The main challenges of the global health law are state-centricity, biases in setting priorities, flawed implementation, fragmentation, duplication, and lack of coordination (57). Downsizing the concept (global health law) in size and scope can be considered health research law, covering all HRS stakeholders. Legislation and laws related to Iran HRS have some malfunctions regarding intellectual property, capacity building, public-private partnership, research processes transparency and motivation, and performance improvement. WHO also mentions Iran HRS's restrictive financial and administrative regulations as a primary challenge (42).
One of Iran HRS's critical challenges is intellectual property, especially national innovation and research systems. Intellectual property legislation has some obstacles in Iran. Intellectual property strengthens research findings, commercialization, and industry relations (58). Along with the amendments to the human resources management laws (like performance evaluation, promotions, capacity building, etc.), IP helps solve many HRS challenges like knowledge translation-related ones, like encouraging research bodies toward KT activities (59).
Transparency in research has some main dimensions: transparency in legislation and performance monitoring, data transparency, open data resources (59), and transparency in analysis and research design. Using ICT enhances access to the legislation related to each step of research process management, and that is how it is expected legislations to lead to transparency (60). The current HRS law's inability to enhance public-private partnership (60) and human resources development (61) are other examples of the legislation and law challenges. By considering the Iran HRS's legislation and law challenges systematically, many contradictions are mainly due to the multiple trustees in this regard (62).
4.2. HRS challenges in Meso level
Challenges that need to be addressed at this level are priority setting, M&E, and using evidence as a base for decision-making. The priority setting is not transparent, participatory, systematic, and efficient (39, 51). Reviewing the nine common themes of good health research practices proposes some features for setting a PS. Some consider the context, key stakeholder’s engagement, determining criteria, setting up an information management system, and defining an evaluation mechanism (63). It is critical to consider a multi-disciplinary approach in engaging the stakeholders (64). Some steps are also proposed at the international level to formulate the health R&D PS by WHO with similar items. It also recommends developing generic guidance that ensures the flexibility and transparency of the PS process (63). In Iran, developing regulation and motivation mechanisms also help (39). Last is the incompatibility of the research activities with national needs and priorities (65). At the same time, it is an indicator used for evaluating the stewardship in an HRS called national focus that measures the compliance of health research activities with national needs (18).
M&E frameworks help to follow the policy goals and targets. Also, it enables tracking the stakeholder's performance, estimating the effectiveness of the policies, and designing the sub-systems. A well-developed M&E provides data collection, analysis, and sharing (66). Iran HRS has challenges in its M&E, especially in measuring the performance of the research bodies, evaluating the priority setting process, being quantitative-oriented, and not considering the effectiveness of the research. The same is true for many other countries' HRS in conducting an effective M&E, enabling the national HRS to set priorities and develop research policy (67). Establishing a governance structure in HRS helps mitigate many of these challenges (68s), particularly the priority setting process and facilitating the strategic plan development (69). Besides the M&E challenges, a fixed governmental budget, despite the performance, leads to low innovation, competitiveness, and motivation in the research environment in Iran (54).
Using evidence in Iran's health policy and decision-making is not well established and not systematic (21, 24). At the same time, research should be embedded in different phases of policymaking, including identifying and prioritizing issues, developing policy solutions, and evaluating the appropriateness of the option. Mainly, the experts refer to the lack of trust among policymakers and researchers, the low quality of some research, and the weakness of both sides as the primary source of the challenges. The political side of an HRS needs to know how to listen to evidence to enhance the research to action and policy (70) and move toward evidence-informed policymaking. Improving the KT-related knowledge of both research bodies and research users’ sides works in enhancing their relation (9). Other suggestions to improve the evidence uptake are restoring trust between sides, considering intellectual property, and encouraging competition.
4.3. HRS challenges in Micro-level
Two issues with more weight at the Mic level are promotion law and communication, networking, and collaboration. The promotion law of faculty members is a clear example of the effects of regulation on capacity building, performance evaluation, and motivations of HRS human resources. It emphasizes quantity instead of research quality and outputs effectiveness and destroys motivation after receiving a complete master's degree (71). This law does not consider community-based research; meanwhile, it is a prominent trend of the research community worldwide (72). Unifying the rules in all disciplines and universities, regardless of the requirements of each, is another critical challenge of this law (71). Instead, considering knowledge translation activities in the performance evaluation of research bodies and observing intellectual property rights in regulations would work (59).
The communication, networking, and collaboration (CNC) challenges in Iran HRS can be classified into three main categories. The first is the CNC of research bodies. There is no networking and data sharing mechanism among researchers and research centers active in Iran HRS, which is the main barrier of knowledge sharing and networking (73). The second is the CNC between research bodies and the research users, including the policymakers and the community (24, 39, 73), while networking in HRS plays a crucial role in improving knowledge management (33). Studies show that Networking helps strengthen initiatives and provide access to global health researchers. WHO has announced stakeholders’ engagement as a solution to HRS challenges, especially in developing countries. Malekafzali et al. cited the lack of trust and commitment of policymakers and managers not to engage the research bodies in related matters. On the other side, research bodies are not sure if their comments issue or not (74). NIEHS endorses six principles for effective community-based participatory research: 1. Active collaboration and participation at every stage of the research 2. Co-learning fostering 3. Ensuring all research activities be community-based four and ensuring that researchers and intervention strategies are culturally adapted 5. They are disseminating results properly 6. Defining community as a unit of identity (75). The third is the lack of CNC among critical stakeholders, making the priority setting process non-systematic and non-transparent (51) that primarily is rooted in the Mac level.