How the policy and stewardship landscape of the National Health Research System looks like in a developing country like Iran: a qualitative study

doi:10.21203/rs.3.rs-1526647/v1

Background: The health research system is an important national priority that requires a systematic and functional approach. Evaluating the HRS of Iran, as a developing country, and identifying its challenges show the significant role of the stewardship-related ones in how the whole system is operating well. The study aims to assess the health research system regarding stewardship functions and highlighting the enhancement points.

Methods: This study was carried out between March 2020 to April 2021 using a systematic review and meta-synthesizing of evidence to examine the Iranian HRS stewardship challenges and interview 42 stakeholders, using a critical case sampling and snowballing approach that some were semi-structured and some in-depth. The interviewees were selected criteria-based, covering the policymakers, managers, research bodies, and NGOs in health research-related fields like higher education, research, technology, innovation, and science. All data were analyzed using the content analysis leading to determining eight main groups of findings under three levels of Macro, Meso, and Micro.

Results: Analyzing the findings leads to eight main themes. The most critical challenges were: not forming an integrated leadership model, and a shared vision among different HRS stakeholders. Their scope and activities had contradictions, and their role was not clarified in a predetermined big picture. The other challenges were in legislation, priority setting, monitoring and evaluation, networking, and using evidence as a decision support base.

Conclusion: Stewardship functions are inappropriately performed, and they are considered the root causes of many other HRS challenges in Iran. Formulating a clear shared vision and formulating the work scope for HRS actors is critical, along with integrating all efforts toward a unified strategy that assists in addressing many challenges of HRS. Developing strategic plans, future-oriented and systematic research, and evaluating the performances. Policymakers and senior managers need to embrace and use evidence, and effective networking and communication mechanisms among stakeholders need to be enhanced. To have an effective HRS, redesigning the processes, regulations, and rules promotes transparency, accountability, being well-organized and systematic.

Health research system (HRS)

stewardship

Iran

Having a systematic approach to health research helps in enhancing the research system efficiently, integrated, and practically.
Stewardship needs attention as the essential function of a national health research system, especially in a developing country like Iran.
The stewardship challenges are the roots of many other malfunctions of an HRS like resource management, knowledge management, capacity building, etc.
The findings can be the basis for further studies and interventions in improving the HRS at the policy making level.
A map of an ideal HRS has been imagined to visualize what we need to have a well-organized HRS.

Health research efforts have received more attention globally during the last two decades, and adopting a systematical approach to the issue has also been improved (1, 2). The starting point that drew attention was the gap between the health research activities and the highest priorities, discussed at the health research conference in Bangkok in 2000 (2). There are two main concepts involved, health research (HR) and HRS. HR refers to knowledge generation methodologically that aims to deal with health problems (3) it is near the second mode of scientific research. In mode one, the science finds its way, but in mode two, it is supposed to benefit the community socially and economically and improve the development path in practice (4). The second concept is the HRS, called the national health research system (NHRS), when it makes sense at the national level. It architectures the components, and stakeholders active in health research, systematically and more importantly, helps mobilize the resources to address national health needs (5).

The HRS has a critical role in health policymaking by generating evidence for addressing the questions (1). As the evidence is highly qualified, need-based, and accountable, it facilitates the path toward universal health coverage, too (6). Articulating the health system and its subsystems, based on their functions, helps capture the components, relations, and synergies of being systematical (7). The stewardship is an initial function of a health system that helps meet the objectives (8). Stewardship and governance, used changeably in HRS frameworks that are considered as the primary function of an HRS with mostly the same sub-functions (9–11), as follows: 1) Setting vision; 2) Developing National strategic health plan; 3) Performance monitoring; 4) Setting Relations, partnerships, processes, regulations, and rules; 5) Intelligence generation; 6) Ensuring accountability, and 7) Priority setting (2, 5, 12–15).

Most of the challenges of the HRSs are rooted in the breakdown of stewardship and governance and related subfunctions (as mentioned above), which is valid for most countries, with more intensity in developing ones (16). Iran HRS is also encountering many malfunctions despite all its improvement in HR in the last three decades (17, 18), so the process of NHRS development has to be redesigned. Most HRS challenges are due to the stewardship malfunction, like a failure of the structural and regulatory framework, processes, and monitoring. Improving the stewardship helps strengthen the NHRS similarly in Iran and other developing countries (11, 16, 19).

Our research team consisting of the managers of the health research grant bodies and health-related research center, and researchers, are encountering so many challenges in our daily activities that motivated us to think about the causes and try to find answers to the questions raised from those challenges. The main question is: how much is Iran's HRS melody harmonious? The first answer that comes to mind as what we experience is, not so much! Trying to find the exact and to the point causes and solutions by initial literature review, the answers were not clear and convergent, so each stakeholder blamed the other. Some blame researchers for their non-practical research efforts (20), and others believe that policymakers are not trusted by the nature of the research and the evidence that can help them take their roles more efficiently (21). Meanwhile, others challenge the national health research system and believe that research capabilities are not used as they should be. Reviewing the literature helped us capture the NHRS concept that has received more attention globally during the last two decades. It also helps adopt a systematical approach to the issue (1, 2).

1.1. Iran HRS structure

Iran has a health research and education unique structure due to the integration of health services and medical education (22, 23). The Ministry of Health and Medical Education (MOHME) is the leading national entity or institution responsible for medical education and health research and technology. Similarly, each university of medical sciences has two vice-chancellors for education and research that research centers are a subset of the Vice Chancellor for Research. This is even though many other organizations are the key stakeholders of HRS regarding its governance and stewardship, directly or indirectly, some of which are: 1-The Islamic Consultative Assembly (Parliament); 2- The Supreme Council for Cultural Revolution that defines broad policies in the field of higher education and culture; 3- The Research and Technology deputy of the MOHME (7, 18); 4- The Plan and Budget Organization (24).

This study tried to analyze Iran’s HRS challenges regarding the stewardship function. We tried to have the Iran HRS stakeholder’s participation as interviewees as wide as possible and review the related evidence systematically to be sure of not missing any data. We expect to provide a base for further studies, implications, and reforms. For this purpose, we tried to have a practical approach in analyzing the data and presenting suggestions. As the importance of the knowledge translation in moving toward a qualified HRS, a conceptual drawing map of the main recommendations is also shown in appendix 2. The picture is developed based on the research findings to illustrate what the Iran HRS needs to be more efficient and improve health.

This is a qualitative, cross-sectional, and descriptive situation analysis study using desk review and interviewing with experts. A brief overview of the phases is presented in Fig. 1. The study is done between March 2020 to April 2021.

2.1. Qualitative systematic review

The research question was: “What are the challenges of Iran HRS from a stewardship perspective?”. The systematic review of qualitative studies and then a meta-summary and meta-synthesis were done based on Sandelowski and Barroso’s guidelines (25). The research team did the systematic review in collaboration with a librarian and data specialist. The Persian databases used in the study were Element, Civilica[1], Irandoc[2], google scholar, scientific information database[3], and Google local domain. The English databases were as follows: Scopus, Web of Science, Science Direct, Emerald, and PubMed. Googling also helped check the gray literature besides database coverage in English and Persian. The investigators have also asked the experts to introduce any document to help complete the gray literature. The search strategy is presented in appendix 1, developed based on SPIDER (26).

2.1.1. Quality appraising and data extraction

The Critical Appraisal Screening Program (CASP) was used for the quality appraisal (27). Figure 2 shows the 2020 updated version of the PRISMA, and the steps are reported based on it, too (28).

Omitting the duplicates: 149 records were investigated through the selected databases, with 42 copies. Also, three were added by asking the experts in the interviewing phase.
Title abstract screening: Two researchers screened the title and abstract independently based on the inclusion and exclusion criteria and then agreed with a senior researcher to avoid selection bias. Finally, 35 records entered the next phase. The inclusion and exclusion criteria were:
- Inclusion criteria: English or Persian studies with qualitative research design, aimed at exploring:
  - Challenges (Iran HRS or general research system of Iran) from stewardship perspective;
  - One specific challenge (Iran HRS or general research system of Iran) related to stewardship sub-functions;
  - Exclusion criterion: Studies focusing merely on research challenges in non-health-related fields.
- Full-text screening: 28 full texts have been screened by peers to enter the next phase. Also, the other record entered the data extraction by interviewing. This record was proposed by senior experts of the Iran HRS that was not available through searching the databases.
- Critical appraisal: 10 papers were excluded by using the CASP tool. Each item was scored as “Yes” or “No” or “Unclear” depending on their appropriateness by the score of “1”, “0”, or “0.5” respectively. As there is no cutoff point for the CASP tool to exclude the records, the researchers agreed to exclude those with less than five scores (less than average).
- Data extraction: Nine papers were selected using a matrix model (29), and one report also entered the data extraction. It was done independently by three peers and checked in pairs to ensure data extraction consistency.

The data, including all included records that their data has been extracted, supporting the conclusions of this article, are included within the article in the Result section and discussion (with citations).

2.2. Interview

The interview approach was a mixture of semi-structured and in-depth questions using two types of sampling, critical case and snowball sampling strategies. The interviews were driven by an exploratory approach to capture the challenges in step one. In step two, a group of interviews was carried out using the explanatory approach to describe and find out the root causes of the challenges. The sampling strategies and methods, data collection, and management are presented in Table 1. Totally 42 interviews were carried out in this study. The interview is reported based on qualitative research reporting standards (30)

Table 1

organizations, sectors, and individuals identified to be the study's target (the interview participation scope)
Criterion	Under the criterion level 1	Under criterion level 2
Organizations	Ministry of health	Science, research and technology deputy
		Education deputy
		Research centers
	Medical sciences universities	Science, research and technology deputy
		Education deputy
		Research centers
	Ministry of Science, Research, and Technology (MSRT)	Universities
	Ministry of Science, Research, and Technology (MSRT)	Research centers
	Entrepreneurship related organization
	NGOs
Sectors	Private sector and health industry
Sectors	National innovation system
Individuals	International experts who know the Iran HRS
	Faculty members and graduate students
	Top Iranian researchers at the international scale
	Researchers active in health-related sections

2.2.1. The sampling strategies for exploratory interviews

The organizations, sectors, and individuals identified as the study's target are presented in Table 1. Before participant's identification, the essential HRS sub-sections and departments (as main stakeholders of Iran HRS) were initiated to be the target group of the study. For this purpose, three experts involved in the Iranian health and scientific systems contributed. The selected department and subsections are government, research center heads, health innovation system, higher education, science, and technology policymaking, senior researchers, HRS, NGOs, graduate students, and international experts of Iran HRS. Participants were identified and selected purposively. After determining the target groups, the strategy was to diversify the participants. The second strategy was to candidate individuals covering more than one category.

2.3. Data collection and management

After getting all experts' lists prepared, personal communications with experts were carried out to identify the appropriate time and date for the interviews. One day before the interview, the researcher communicating with experts sent a summary of the study objectives, consent form, and formal invitation. Two methods of structured and in-depth interviewing were used for data collection.

The in-depth interview was designed for senior experts and policymakers to elaborate on more technical and strategic ideas and let it open to them to express their perceptions of Iran HRS challenges. The semi-structured interview was used to ask to-the-point questions. Twenty-two interviews were done structured and ten in-depth. Choosing an in-depth approach was based on two main reasons:

Senior stakeholders like policymakers with insight about HRS due to their executive and managerial experiences
The participants whose tendency was to point to the issues without structure and based on their conceptual model

The researcher had a guide in mind to know the participant's idea. The researcher attempted to change the direction during the interviewing, if necessary. Thus, the in-depth interviews helped develop the conceptual map of the Iran HRS stewardship challenges. In contrast, the structured ones added more details and implications of the Iran HRS stewardship challenges. All the explanatory interviews are done using the in-depth approach to capture the roots and causes as much as possible.

The interviews were conducted virtually using Microsoft team, skype, and phone. The principal investigator did the interviews and transcribed the texts. The interviews were recorded with permission, recorded by AnyMP4 screen recorder for the Skype and Microsoft team interviews and call recorder for on calls. The structured interviews took 45 minutes on average, varying between 30 to 60, and the in-depth interviews took 60 minutes on average, ranging between 45 to 75 minutes.

The systematic review and interviewing results were analyzed using the framework analysis method. The MAXQDA 2018 was used for framework analysis. The software helped code the systematic review and qualitative meta-synthesis and interviews. After the framework analysis, all the codes related to the stewardship were reanalyzed to develop a conceptual model of the Iran HRS from the stewardship perspective. The approach was content analysis, and the results of both steps are reported based on COREQ (31).

2.4. Validity and quality check

The following steps were taken to avoid misleading, reporting bias, or any other kind of unconscious bias:

The transcribed text of the interviews was checked by a peer in the research team before the qualitative analysis step to ensure the quality and validity of the results.

After the qualitative analysis, a national virtual session was held by the participants involved. The preliminary results of the qualitative analysis of the interviews in alignment with the review results have been presented to receive the stakeholder feedback and comments. There were also more codes mentioned in the session by participant's debate. The session helped the research team avoid biases, improve the themes and codes, sensitize the stakeholders on results, and let them know the study progress they have been involved in.

[1] CIVILICA or Knowledge Reference is a private website that indexes and publishes a collection of conference papers and conferences in Iran. Civilica is a member of the National Content Consortium and, in this national consortium, is the only provider of data from specialized conferences and seminars in Iran. Available at https://civilica.com/

[2] Irandac's core mission is research, science and technology information management, education, research and information collaboration, and science and technology policy support, which is carried out in an organization affiliated with the Ministry of Science, Research, and Technology and under the auspices of the Board of Trustees. Available at https://irandoc.ac.ir/

[3] Scientific Information Database (SID) of Academic Center for Education, Culture and Research Persian is an Iranian free accessible website for indexing academic journals and access to full text or metadata of Academic publishing. Available at https://www.sid.ir/

The results obtained from both reviewing and interviewing are presented after content analysis. Using both data collection instruments helped us articulate a map of the challenges and their potential and active relations. The data mentioned here as the study results are gained from the qualitative analysis of both data sources (desk review and interview) using content analysis to determine the main themes and codes. The results were classified into eight characteristics groups and three levels of Macro, Meso, and Micro, combining the content of interviews with the findings from the desk review. The Mic level includes research bodies (research centers and universities) and researchers (like faculty members and postgraduate students). The Mes level is considered within the MOHME authority that its education and research deputies are the main structures related to HR. The Mac level is considered beyond the MOHME authority. At the national level, including the key stakeholders like the supreme council of the cultural revolution and the Expediency Discernment Council, the MOHME is not the only stakeholder.

The eight groups are as follows, and Table 2 shows a brief overview of the findings: 1) Leadership; 2) Vision; 3) Priority setting; 4) Structure; 5) Regulation; 6) Monitoring and evaluation; 7) Communication, networking, and collaboration; and 8) Evidence-based/informed decision-making. For example, for the first feature, leadership, it is not clear at the Mac level, which means that at the Mac level, there is no transparent, predetermined leadership model or mechanism to determine a shared vision and lead the stakeholders in moving toward it. There is a defined structure between the MOH and its research deputy at the Mes level, but the results show malfunctions in leadership. At the Mic level, leadership is not functional and efficient based on the results. The status of other features is also presented in Table 2.

Table 2

The challenges of Iran HRS from a stewardship perspective
Features	Macro At national scale (not restricted to MOHME)	Meso (Within the authority of MOHME)	Micro Research bodies and researchers
Features	Status	Status	Status
Leadership	Not clear	Defined structure with malfunctions	Non-functional Not efficient
Vision	Not defined	Not defined	Not determined or expressed inefficiently Not aligned with a big picture
Priority setting	Not well-defined Not transparent Not participatory Not systematic Not Future-oriented Not efficient	Not well-defined Not transparent Not participatory Not systematic Not efficient Not Future-oriented Unmatched with national development needs	Not aligned with a big picture or not defined
Structure	Non-harmonized multiple actors Overlapped scope of stakeholders Inefficient in conflict-of-interest management Under the influence of Political dominance Non-agile	Inefficient Centralized Bureaucratic Under the influence of Political dominance Not sustainable Contradictory in conflict-of-interest management Non-agile Not updated	Non-uniform Dependent The gap between theory and practice Inadequate in conflict-of-interest management Non-agile
Regulation	Contradictory Inefficient in: • Incentives • Intellectual property • Capacity building • Public-private partnerships • Enhancing international scientific relations • Research structure development	Contradictory Inefficient in: • Research process management • Enhancing transparency	Inefficient in: Motivating researchers Performance improvement
Research monitoring and evaluation	Not defined	Not well-defined Non harmonized Non-standardized Non-systematic Non-dynamic Inefficient Quantitative One dimensional	Not well-defined Non harmonized Non-standardized Non-systematic Non-dynamic Inefficient Quantitative One dimensional
Communication, networking, and collaboration	Not defined (among critical stakeholders) Not practical	Not well defined (among critical stakeholders) Inefficient Not practical	Not well defined (among research bodies and individuals) Inefficient Not practical
Evidence-based/informed decision-making	Not well defined Not efficient Less trusted in Non-functional Not being in priority	Not well defined Not efficient Less trusted in Non-functional Not being in priority	Not motivated in Not efficient in responding to

3.1. leadership

Complexity and lack of collective leadership are some of the main concerns, particularly at the MAC level, while the matter was also highlighted in MES and MIC levels. There are long-term plans at the MAC level, but leadership and legal obligation to persuade all role stakeholders to follow its advice are not well-defined.

3.2. vision

Regarding the vision as an essential function of the HRS stewardship, a shortage of shared vision among stakeholders was identified at both Mac and Mes levels in Iran. This means that health research activities at the Mic level are misaligned with the overall strategic direction of HRS in the country. Furthermore, most research institutions have no vision that manages, regulates, or monitors the research.

3.3. Priority setting

The priority setting is not well-defined, transparent, participatory, systematic, future-oriented, and efficient at the Mac and Mes levels, and the priorities defined at the Mes level are not matched with national development needs so that the preferences of the research bodies and researchers are not aligned with an upper national one.

3.4. Structure

Multiple stakeholders at the Mac level are acting non-harmonized with many overlaps and contradictions in their scopes (regarding health research). Conflict of interest management also matters at all three levels. The structure of health research is centralized, bureaucratic, and influenced by political dominance. The policy dominance also exists at the Mes level, leading to the unsustainability of the HRS. The structure at the Mic level is not correctly uniform and varies in cases (in different research bodies). Research bodies' system is dependent on the centralized design at the Mes level and is mainly supported by a fixed governmental budget. The design of HRS is not agile enough in all three levels and has not been updated based on new requirements, context, and research environment.

At the Mes level, the HRS is not aligned with the education system, referring to the challenge of separating two functions of education and research at both Ministry and its underlying units (like universities and research bodies). Education and research are not the main priority of the MOHME and medical universities.

3.5. Regulation

The Regulations regarding HRS are inefficient in incentives, intellectual property, capacity building, and public-private partnership matters, with many contradictions. They also were not as efficient in research structure development as it was supposed to be. Regulations set at the MOHME authority also have contradictions. They are not efficient enough in facilitating and managing the research process (from defining research to evaluating). Laws could not make the processes transparent, like setting research priorities and resource allocation. At the Mic-level, rules and regulations are almost inefficient in motivating research and performance improvement.

3.6. Research monitoring and evaluation

A research monitoring and evaluation system have not been defined at the Mac level of HRS, and those of the Mes level are not explained well. It's not harmonized, standardized, systematic, and dynamic, leading to malfunctioning the monitoring and evaluating mechanism. Similarly, it's true in monitoring and assessing the performance of research bodies at the Mic-level of HRS.

3.7. Communication, networking, and collaboration

The inter-sectoral and cross-sectional collaboration mechanism has not been defined. No communication, networking, and collaboration mechanism is limited at the Mac level among key stakeholders of this scale. At the Mes level, it has not been well defined among the critical stakeholders in the authority of the MOHME scale. The same is accurate at the Mic-level, and the communication, networking, and collaboration among research bodies and individual researchers are not well defined with less efficiency.

3.8. Evidence-based/informed decision-making

Evidence-based/informed decision-making has not entered the HRS structure as it should be and is not well defined at the Mac and Mes levels. There is less linking of research to action and policy. Research is not primarily the priority for those potential clients, policy, and decision-makers at the Mac and Mes levels. The research bodies also could not respond to required evidence with expected quality at the right time, leading to less motivation and trust of both research clients and research bodies.

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.

Looking up the health research activities as a system is binding in some aspects. Most notably, setting up vision and targets, determining the components, and defining the relations, processes, and rules. Achieving all those features requires effective stewardship of the NHRS. Following up the roots and causes shows that despite other functional challenges of the Iran HRS, stewardship issues are more weighted and more fundamental than other HRS malfunctions. The research question stated as a challenge that this study investigator encountered every day of their managing and research tasks and trying to find the answers. It is also others question and problem. Iran HRS has started its improvement, but still, there are some works to do. It has missed a potential synergy among critical stakeholders that improving a focal leadership seems essential. It can lead to defining a vision that mobilized the research efforts comprehensively and harmonized, like a big joint picture that all resources be mobilized to complete its puzzle. This enhancement will spread to any individual active in HRS too. Reviewing rules and regulations, strengthening cross-sectoral and intra-sectoral links, restructuring the priority setting, incorporating evidence-based decision-making, increasing transparency and effectiveness in research processes at all Mac, Mes, and Mic levels, and finally strengthening the networking among stakeholders are other solutions that will help enhance the research of health system from a stewardship perspective.

As the nature of the stewardship scale, we hope to draw the attention of national policymakers in Iran and those related intergovernmental ones like WHO that can make a difference or at least start the journey to reforms for Iran or any other developing country in improving their HRS, systematic and framework-based. Each sub-functions-related recommendation needs attention at policy-making and leadership scale-like developing practical planning in separate studies. This study had some limitations, like access to some top policymakers. If possible, providing a mechanism for all stakeholders' participation in finding and making sense of the challenges can help improve this study's results and, more importantly, achieve consensus on issues and solutions among stakeholders. This gathering needs top-managers will and other stakeholders' motivation to participate. We tried to have the NGO's comments in the study as the representative of the community but engaging the community on a broader scale can help too.

HRS: Health Research System; NHRS: National Health Research System; CNC: Communication, Networking, and Collaboration; M&E: Monitoring and Evaluation; MSRT: Ministry of Science, Research, and Technology; CASPP: Critical Appraisal Screening Program; MOHME: Ministry of Health and Medical Education; Mic: Micro; Mes: Meso; Mac: Macro.

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Availability of data and materials

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Competing interests

The authors declare that they have no competing interests

Funding

No funding received

Authors' contributions

AP participated in the conceptualization and setting of the research design, doing the interviews, data extraction of articles, qualitative analysis of the interviews and meta-synthesis, data analysis, and interpretation of the challenges. MA participated in qualitative analysis and interpretation of the challenges, and reviewed and edited the manuscript. RD participated in the conceptualization and setting of the research design, data analysis, and interpretation of the challenges and meta-synthesis and coordinated the interviews. AH participated in the conceptualization and setting of the research design, data analysis, and interpretation of the challenges, coordinated the interviews, and is the correspondence author. AM participated in data validation, records screening of the systematic review, data extraction, qualitative analysis, data analysis, interpretation of the challenges, and manuscript edition. SN participated in qualitative analysis, data extraction, and manuscript edition. MC and MB set the search strategy, did the systematic search, and classified the records. All authors read and approved the final manuscript.

Acknowledgments

We thank all interviewees who participated in the study despite their preoccupation and Mis Zahra Baghkhani for designing the appendix 2 graph.

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How the policy and stewardship landscape of the National Health Research System looks like in a developing country like Iran: a qualitative study

Status:

Version 1

Abstract

Figures

Contributions To The Literature

Background

1.1. Iran HRS structure

Method