Agenda-setting for pharmaceutical subsidy reform in Iran: a qualitative multiple streams analysis of the Darooyar...

Pharmaceutical subsidy reform is among the most politically sensitive policy challenges in health systems, particularly in contexts characterized by economic instability and external constraints. In Iran, persistent medicine shortages, fiscal pressures, and concerns regarding inefficiencies in the preferential exchange-rate system culminated in the introduction of the Darooyar reform in 2022. This study aimed to examine how the Darooyar reform reached the governmental agenda by applying Kingdon's Multiple Streams Framework (MSF).

A qualitative policy analysis was conducted using Kingdon's MSF as the analytical framework. Data were collected through semi-structured interviews with 16 key informants, including policymakers, health managers, academics, pharmacists, insurance representatives, and pharmaceutical-sector experts. Interviews were supplemented by a review of policy documents, legislative reports, official records, and relevant literature. Data were analyzed using framework analysis and organized around the problem, policy, and politics streams, as well as policy entrepreneurs and policy windows.

The findings showed that the Darooyar reform emerged through the convergence of three streams. In the problem stream, long-standing fiscal pressures, governance failures, and market distortions became agenda-relevant following medicine shortages and corruption-related concerns in late 2021. In the policy stream, several alternatives competed for attention, including maintaining the preferential exchange rate, full liberalization with cash transfers, and an insurance-based subsidy model. The Darooyar proposal gained prominence because it was technically developed, administratively feasible, and supported by key health-sector institutions. In the politics stream, executive commitment, parliamentary support, Central Bank pressures, and sanctions-related constraints increased receptivity to reform. Policy entrepreneurs within the Ministry of Health and the Iran Food and Drug Administration coupled these streams during the 2022 budget process, creating a policy window that facilitated agenda entry.

The Darooyar case demonstrates how pharmaceutical policy reform can reach the governmental agenda through the interaction of problem recognition, policy preparedness, political receptivity, and entrepreneurial action. The findings extend the application of MSF to sanction-affected and resource-constrained settings and highlight the importance of institutional preparedness and technocratic policy entrepreneurship in shaping health policy agenda-setting.