Hospital Preparedness for CBRNE Threats in Iran: A Qualitative Policy Analysis of Risk Assessment Using the Walt and Gilson Framework

Chemical, biological, radiological, nuclear, and explosive (CBRNE) threats are among the complex and multidimensional crises that pose serious challenges to health systems. Hospitals, as the frontline in dealing with these threats, require structured preparedness based on documented policy frameworks. This article aims to conduct a policy analysis of risk assessment in the management of CBRNE incidents in hospitals of Iran based on the Walt and Gilson policy triangle framework.

This policy analysis examined the four dimensions of content, context, actors, and process in hospital CBRNE preparedness policies using the Walt and Gilson framework. Data were collected through 14 semi-structured, in-depth interviews with purposively sampled experts, managers, and specialists (emergency medicine, hospital administration, and health policy) in Iran; sampling continued until data saturation was achieved. Data were analyzed using framework content analysis, and trustworthiness was ensured through the Lincoln and Guba criteria (credibility, transferability, dependability, and confirmability).

The findings showed that in terms of content, the main gaps were the absence of an integrated governance and crisis command structure, unclear accountability, and a lack of standardized policies and procedures. Regarding context, security, economic, and technological factors - including hybrid and cyber threats and resource constraints - strongly shaped preparedness. With respect to actors, CBRNE management emerged as inherently multi-sectoral, dependent on coordination among internal hospital actors and external organizations. Finally, in terms of process, risk assessment was seen as a continuous cycle weakened by the absence of structured feedback and the failure to use lessons learned, reflecting a persistent gap between policy formulation and implementation.

Applying the Walt and Gilson framework to CBRNE risk management in Iranian hospitals offered analytical insight into the gaps in hospital preparedness rather than generalizable findings, given the qualitative design and purposive sampling. The study suggests that strengthening inter-organizational cooperation, developing standard protocols, allocating resources, and ensuring continuous staff training are important strategies for improving hospital resilience. On this basis, the authors propose that establishing a national CBRNE risk-management framework, reinforcing intersectoral coordination, developing technological infrastructure, and institutionalizing monitoring and policy learning warrant consideration as policy priorities.