Why Iran’s Parliament Struggles to Shape Health Policy: A Power Analysis

Parliaments are supposed to be the beating heart of democratic health governance. They write the laws that determine who gets vaccinated, how hospitals are funded, and whether pharmaceutical regulators have teeth. Yet in many countries, the practical influence of legislators on health policy remains strikingly shallow, squeezed between powerful executive ministries, technical agencies and professional elites who dominate the drafting of health legislation. A new qualitative study from Iran, published in Health Research Policy and Systems, offers one of the most detailed anatomies yet of why legislative engagement in health policymaking so often falls short, and its findings resonate far beyond one country’s borders.

The research team, led by Meysam Behzadifar of Lorestan University of Medical Sciences with colleagues from Tehran University of Medical Sciences, Iran University of Medical Sciences and the University of Genoa, set out to map the challenges facing parliamentary engagement in Iranian health policymaking. Rather than simply cataloguing institutional weaknesses, the researchers adopted a sophisticated analytical lens: Gaventa’s power cube framework, a conceptual tool developed in the field of participation studies that dissects power across three dimensions. The framework distinguishes between the spaces in which decisions are made, the levels at which governance operates, and the forms that power takes, whether visible, hidden or invisible.

To build their picture, the team conducted semi-structured interviews with 32 participants who had direct or indirect involvement in health legislative processes. The sample was deliberately diverse, assembled through purposive maximum variation sampling, and included senior health officials, health policy advisors with hands-on parliamentary experience, representatives from insurance and regulatory bodies, members of professional associations, and academic researchers specializing in health policy. Interviews were semi-structured, allowing participants to describe their experiences in their own terms, and the resulting data were analysed using reflexive thematic analysis. The researchers began with inductive coding, letting themes emerge from the material itself, and then moved to an abductive theoretical interpretation, reading those themes through the dimensions of the power cube.

The first major finding concerns where decisions actually happen. The study found that parliamentary engagement in Iranian health policy occurred largely within what Gaventa calls invited spaces, formal arenas to which legislators are granted access by more powerful actors. Meanwhile, the crucial agenda-setting processes, the moments when problems are defined, options are framed and priorities are fixed, remained concentrated in closed spaces: executive boardrooms and expert committees that operate beyond public or legislative view. These closed spaces were not merely accidental. The researchers found they were actively reinforced by hidden power mechanisms, including selective information dissemination, in which decision-relevant data flowed only to favoured actors, and strategic control over policy framing, which determined how health problems were understood before Parliament ever saw them.

This distinction between invited and closed spaces is technically important because it reframes the problem of legislative weakness. A parliament can be formally empowered, constitutionally entitled to legislate and oversee the executive, and still be structurally sidelined if the substantive work of policy formulation happens upstream. By the time a health bill reaches the legislative chamber, its essential contours may already have been fixed in arenas the legislature never entered. The Iranian case suggests that parliamentary reform efforts that focus only on formal powers, such as strengthening committee mandates or expanding legislative authority, may miss the deeper point: access to the spaces where agendas are set matters as much as the authority to vote on the results.

The second theme that emerged concerns governance levels. Iran’s health system is characterized by fragmented authority distributed across multiple institutions and tiers of government, a fragmentation that, according to the study, dilutes accountability and constrains effective legislative oversight. When responsibility for a policy area is scattered across ministries, insurance organizations, regulatory bodies and professional councils, no single actor can be held clearly answerable, and parliament’s oversight function becomes correspondingly diffuse. Legislators seeking to scrutinize a health program may find that the levers of control are spread across institutions with overlapping and unclear mandates, making it difficult to identify where a failure originated or who should respond.

Layered on top of this domestic fragmentation, the study identified a transnational dimension that further complicated parliamentary influence. International sanctions, the activities of global health organizations, and external resource constraints all introduced forces that operated beyond the reach of national legislators. Sanctions, in particular, can reshape the fiscal and material environment of health policy without any legislative deliberation, while engagement with international bodies often proceeds through executive channels. This adds an additional layer of complexity to the power cube’s vertical axis: decisions at global and regional levels cascade into national health policy in ways that a national parliament can observe but rarely shape.

The third theme is perhaps the most conceptually striking. The researchers found that the visible powers of the legislature, its formal legislative, budgetary and oversight functions, were continuously shaped by hidden and invisible forms of power. Hidden power, in Gaventa’s schema, operates through the control of information and agenda-setting, deciding what gets discussed and what never reaches the table. Invisible power operates more subtly still, shaping what people themselves come to believe is legitimate, possible or true. In the Iranian health system, the study found that invisible power was anchored in professional authority and dominant expert discourses: the sheer epistemic prestige of medical and technical expertise meant that legislative actors often internalized the notion that health policy was best left to specialists, ceding ground without any explicit contest.

Crucially, the study’s central analytical contribution is the demonstration that these three forms of power did not operate in isolation. Instead, they interacted to create a self-reinforcing cycle. Invisible power, expressed through professional legitimacy, served to legitimize the closed spaces where real decisions were made: if experts are the rightful custodians of health knowledge, then expert-dominated arenas appear natural rather than exclusionary. Hidden power, expressed through agenda control, then operated within the fragmented governance structures to dilute accountability, scattering responsibility so that no clear point of democratic leverage remained. The result is a system in which Parliament’s capacity to influence policy formulation is structurally limited, and legislative engagement becomes predominantly reactive, responding to bills and crises after the decisive choices have already been made, rather than proactive, shaping health priorities from the outset.

The authors argue that their findings carry implications well beyond Iran. Applying Gaventa’s power cube framework to a national health system reveals how executive dominance, institutional fragmentation, transnational pressures and epistemic authority can collectively constrain legislative participation even in systems with formal democratic structures. For reformers, the lesson is that strengthening parliamentary engagement requires more than procedural fixes. It requires opening the closed spaces where agendas are set, clarifying accountability across fragmented governance levels, and confronting the invisible power of expert discourses that quietly defines the boundaries of legitimate legislative action. By showing how closed spaces, fragmented levels and interacting forms of power mutually reinforce one another, the study offers a more nuanced understanding of parliamentary engagement in complex health governance systems, and a conceptual map for anyone seeking to make legislatures genuine participants in evidence-informed health policy rather than spectators to it.

Subject of Research: Parliamentary engagement and power dynamics in health policymaking in Iran

Article Title: Challenges of parliamentary engagement in health policymaking in Iran: a qualitative study using Gaventa’s power cube framework

Article References: Behzadifar, M., Darvishi Teli, B., Bakhtiari, A., Aalipour, A., Azari, S., Martini, M., & Behzadifar, M. (2026). Challenges of parliamentary engagement in health policymaking in Iran: a qualitative study using Gaventa’s power cube framework. Health Research Policy and Systems. https://doi.org/10.1186/s12961-026-01542-w

Image Credits: AI Generated

DOI: 10.1186/s12961-026-01542-w

Keywords: parliamentary engagement, health policymaking, Gaventa power cube, legislative oversight, governance fragmentation, Iran, qualitative study, health governance, policy spaces, invisible power, agenda-setting, Health Research Policy and Systems