Volume 12, Issue 1 (10-2024)
Jorjani Biomed J 2024, 12(1): 18-22 |
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PourBagher S, Bay A, Heydari A. Agenda setting analysis for social health policies of the ministry of health of Iran based on Kingdon's Multiple Streams Model. Jorjani Biomed J 2024; 12 (1) :18-22
URL: http://goums.ac.ir/jorjanijournal/article-1-993-en.html
URL: http://goums.ac.ir/jorjanijournal/article-1-993-en.html
1- Department of Political Science, Islamic Azad University, Azadshahr Branch, Azadshahr, Iran
2- Department of Political Science, Islamic Azad University, Azadshahr Branch, Azadshahr, Iran ,phd_bay1979@yahoo.com
3- Health Management and Social Development Research Center, Golestan University of Medical Sciences, Gorgan, Iran
2- Department of Political Science, Islamic Azad University, Azadshahr Branch, Azadshahr, Iran ,
3- Health Management and Social Development Research Center, Golestan University of Medical Sciences, Gorgan, Iran
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Introduction
Social health has emerged as a critical dimension of health alongside physical, mental, and spiritual well-being. The modern concept of health transcends the absence of physical and mental diseases, incorporating human interactions and societal engagement as critical evaluators of individual and collective health (1). Social health is arguably more sensitive and critical than physical and mental health because its influencing factors can continuously affect an individual's relationships and a broader population. Unlike physical health issues, which have limited effects, threats to social health can disrupt social interactions and roles, making it a complex and subtle area to address (2).
Achieving social health involves engaging in social activities, fulfilling social roles, and adhering to societal norms. It encompasses several factors indicative of an individual's performance in social life (3). Research indicates that individuals with robust social relationships have a 50% higher chance of survival (4). The risks associated with low social connections are comparable to smoking and surpass those of obesity and alcohol abuse in terms of premature mortality (5-8). Social isolation is linked to a 29% increase in coronary heart disease (9) and a 32% increase in the risk of stroke (10), dementia, and memory loss among the elderly (11).
Iranian experts define social health indicators to include the eradication of poverty, violence, gender discrimination, unemployment, and ethnic-racial-regional discrimination. They also emphasize the control of population growth, equality before the law, observance of human rights, compulsory education up to middle school, access to health services, security, freedom of opinion, life satisfaction, universal insurance, fair income distribution, government legitimacy, democratic election of rulers, and public oversight (12). In recent years, social health interventions have gained prominence in health systems due to their importance in social accountability and their dual role as risk factors (Social harm) or protective factors (Healthy social behaviors and an enhancing environment), influencing disease burden through social capital (13).
Policy-making involves four stages: setting the agenda, formulation, implementation, and policy evaluation. Setting the agenda is crucial as it significantly impacts subsequent stages (14). Kingdon's model is a validated framework to simplify these processes by examining three streams: problems, solutions, and political determination (15). The problem stream includes societal issues and circumstances. The solution stream comprises alternatives proposed by researchers and experts. The political stream encompasses political changes, national situations, and social pressures. At certain times, these streams converge, creating a policy window where specific policies are prioritized and placed on the agenda (16-18).
Limited studies have addressed the challenges and solutions to improving social health (13,19). However, to our knowledge, no study has elucidated the process of introducing social health policies to the agenda in Iran using a valid policy model. This study aims to fill that gap by applying Kingdon's multiple streams framework to determine how social health policies were incorporated into the Ministry of Health's agenda and identify the factors influencing these changes. The findings will offer valuable insights for health policymakers on factors affecting social health policy implementation and inform future policies and initiatives in this domain.
Methods
This inductive qualitative study was conducted in 2022. A qualitative approach was chosen due to the subject's novelty, the absence of standardized measurement instruments, its significance, the complexity and multidimensional nature of the process, the limited number of experts, and the similarity among the community members under investigation.
The participants included fifteen managers and scientific and executive experts from the Ministry of Health (4 participants), the Ministry of Interior (2 participants), the Governor's Office (2 participants), universities of medical sciences (4 participants), and non-governmental organizations (3 participants). The interviewees were selected based on their executive experience, knowledge of social policies, and willingness to participate. Data were collected through semi-structured interviews guided by a framework developed based on Kingdon's model. The questions focused on three streams: the problem stream (Description, dimensions, and importance of the issue), the policy stream (A set of political solutions proposed by experts, politicians, government employees, and interest groups), and the political stream (General political atmosphere and policies affecting issue resolution).
Additional questions were posed during the interviews to clarify and elaborate on the provided information. Data collection continued until saturation, which occurred at the fourteenth interview, ensuring no new codes were generated and existing codes were repetitive. One additional interview was conducted to confirm the adequacy of the sample.
The interviewer, one of the authors with expertise in the topic, conducted each interview, which lasted between 25 and 55 minutes, with an average duration of 35 minutes.
Before each interview, the study's objectives were thoroughly explained to the participants. Interviews were recorded with the participant's consent, ensuring confidentiality and anonymity. Notes were taken during the recordings to document observations. The interviews were transcribed immediately after recording, and participants were consulted to verify the accuracy of the transcriptions. Each interview was then coded.
To ensure the accuracy and reliability of the data, the study adhered to Lincoln and Guba's criteria of credibility, transferability, dependability, and confirmability (20-22). Participant validation was used to confirm data and code accuracy. To enhance reliability, primary codes and examples of extracted themes were reviewed by an external observer for consistency with the researcher's findings. The supervisor, an expert in qualitative methodology with a doctorate in healthcare management, reviewed the data coding process. Verifiability was ensured by presenting several interviews, extracted codes, and themes to qualitative research experts who did not participate in the study. Data transferability was validated by comparing the current findings with prior research outcomes.
The research ethics committee of Golestan University of Medical Sciences approved the study (IR.GOUMS.REC.1401.116). Oral consent was obtained from participants, and interviews were recorded with their permission. Participant information remained confidential, and participants could withdraw from the study any time.
The interview data were analyzed using the framework analysis method, which includes five main steps: familiarization, identifying a thematic framework, indexing, charting, mapping, and interpretation. All interview stages, including listening to recordings, reading transcripts, and reviewing interviews, were part of the familiarization process. Recorded interviews were revisited for thorough review and question completion. Based on literature related to Kingdon's model dimensions, the initial conceptual framework was finalized with approval from the supervisor and advisor. In the indexing stage, the text was coded according to the themes and sub-themes of the conceptual framework. The data were then summarized in thematic tables, providing an overview of primary data in one place. During the mapping and interpretation stage, the data were reviewed according to the conceptual framework, and tables were created for each theme, with rows representing interviewees and columns indicating themes and sub-themes. The researcher repeatedly reviewed and completed the main files during the analysis period. The resulting graph was interpreted to compare data across individuals and sub-themes and to investigate relationships between themes and sub-themes. As the texts were in Persian, a manual method was employed to enhance creativity in topic classification rather than standard software.
Results
The main components of Kingdon's model include three streams:
Social health has emerged as a critical dimension of health alongside physical, mental, and spiritual well-being. The modern concept of health transcends the absence of physical and mental diseases, incorporating human interactions and societal engagement as critical evaluators of individual and collective health (1). Social health is arguably more sensitive and critical than physical and mental health because its influencing factors can continuously affect an individual's relationships and a broader population. Unlike physical health issues, which have limited effects, threats to social health can disrupt social interactions and roles, making it a complex and subtle area to address (2).
Achieving social health involves engaging in social activities, fulfilling social roles, and adhering to societal norms. It encompasses several factors indicative of an individual's performance in social life (3). Research indicates that individuals with robust social relationships have a 50% higher chance of survival (4). The risks associated with low social connections are comparable to smoking and surpass those of obesity and alcohol abuse in terms of premature mortality (5-8). Social isolation is linked to a 29% increase in coronary heart disease (9) and a 32% increase in the risk of stroke (10), dementia, and memory loss among the elderly (11).
Iranian experts define social health indicators to include the eradication of poverty, violence, gender discrimination, unemployment, and ethnic-racial-regional discrimination. They also emphasize the control of population growth, equality before the law, observance of human rights, compulsory education up to middle school, access to health services, security, freedom of opinion, life satisfaction, universal insurance, fair income distribution, government legitimacy, democratic election of rulers, and public oversight (12). In recent years, social health interventions have gained prominence in health systems due to their importance in social accountability and their dual role as risk factors (Social harm) or protective factors (Healthy social behaviors and an enhancing environment), influencing disease burden through social capital (13).
Policy-making involves four stages: setting the agenda, formulation, implementation, and policy evaluation. Setting the agenda is crucial as it significantly impacts subsequent stages (14). Kingdon's model is a validated framework to simplify these processes by examining three streams: problems, solutions, and political determination (15). The problem stream includes societal issues and circumstances. The solution stream comprises alternatives proposed by researchers and experts. The political stream encompasses political changes, national situations, and social pressures. At certain times, these streams converge, creating a policy window where specific policies are prioritized and placed on the agenda (16-18).
Limited studies have addressed the challenges and solutions to improving social health (13,19). However, to our knowledge, no study has elucidated the process of introducing social health policies to the agenda in Iran using a valid policy model. This study aims to fill that gap by applying Kingdon's multiple streams framework to determine how social health policies were incorporated into the Ministry of Health's agenda and identify the factors influencing these changes. The findings will offer valuable insights for health policymakers on factors affecting social health policy implementation and inform future policies and initiatives in this domain.
Methods
This inductive qualitative study was conducted in 2022. A qualitative approach was chosen due to the subject's novelty, the absence of standardized measurement instruments, its significance, the complexity and multidimensional nature of the process, the limited number of experts, and the similarity among the community members under investigation.
The participants included fifteen managers and scientific and executive experts from the Ministry of Health (4 participants), the Ministry of Interior (2 participants), the Governor's Office (2 participants), universities of medical sciences (4 participants), and non-governmental organizations (3 participants). The interviewees were selected based on their executive experience, knowledge of social policies, and willingness to participate. Data were collected through semi-structured interviews guided by a framework developed based on Kingdon's model. The questions focused on three streams: the problem stream (Description, dimensions, and importance of the issue), the policy stream (A set of political solutions proposed by experts, politicians, government employees, and interest groups), and the political stream (General political atmosphere and policies affecting issue resolution).
Additional questions were posed during the interviews to clarify and elaborate on the provided information. Data collection continued until saturation, which occurred at the fourteenth interview, ensuring no new codes were generated and existing codes were repetitive. One additional interview was conducted to confirm the adequacy of the sample.
The interviewer, one of the authors with expertise in the topic, conducted each interview, which lasted between 25 and 55 minutes, with an average duration of 35 minutes.
Before each interview, the study's objectives were thoroughly explained to the participants. Interviews were recorded with the participant's consent, ensuring confidentiality and anonymity. Notes were taken during the recordings to document observations. The interviews were transcribed immediately after recording, and participants were consulted to verify the accuracy of the transcriptions. Each interview was then coded.
To ensure the accuracy and reliability of the data, the study adhered to Lincoln and Guba's criteria of credibility, transferability, dependability, and confirmability (20-22). Participant validation was used to confirm data and code accuracy. To enhance reliability, primary codes and examples of extracted themes were reviewed by an external observer for consistency with the researcher's findings. The supervisor, an expert in qualitative methodology with a doctorate in healthcare management, reviewed the data coding process. Verifiability was ensured by presenting several interviews, extracted codes, and themes to qualitative research experts who did not participate in the study. Data transferability was validated by comparing the current findings with prior research outcomes.
The research ethics committee of Golestan University of Medical Sciences approved the study (IR.GOUMS.REC.1401.116). Oral consent was obtained from participants, and interviews were recorded with their permission. Participant information remained confidential, and participants could withdraw from the study any time.
The interview data were analyzed using the framework analysis method, which includes five main steps: familiarization, identifying a thematic framework, indexing, charting, mapping, and interpretation. All interview stages, including listening to recordings, reading transcripts, and reviewing interviews, were part of the familiarization process. Recorded interviews were revisited for thorough review and question completion. Based on literature related to Kingdon's model dimensions, the initial conceptual framework was finalized with approval from the supervisor and advisor. In the indexing stage, the text was coded according to the themes and sub-themes of the conceptual framework. The data were then summarized in thematic tables, providing an overview of primary data in one place. During the mapping and interpretation stage, the data were reviewed according to the conceptual framework, and tables were created for each theme, with rows representing interviewees and columns indicating themes and sub-themes. The researcher repeatedly reviewed and completed the main files during the analysis period. The resulting graph was interpreted to compare data across individuals and sub-themes and to investigate relationships between themes and sub-themes. As the texts were in Persian, a manual method was employed to enhance creativity in topic classification rather than standard software.
Results
The main components of Kingdon's model include three streams:
- Problem stream
- Policy stream
- Politics stream
The results of this study were classified into three main topics (problem stream, policy stream, and political determination stream) and ten sub-topics (Table 1).
Problem stream
The primary issue in policy-making for social health is the absence of a clear definition of social health that all stakeholders accept. The field of social health is inherently complex and multidimensional, with significant differences in the roles, duties, and social activities of society's members. Unfortunately, the Ministry of Health managers, brokers, and agents are often not adequately informed about these aspects. Social factors significantly impact health.
One participant noted, "The field of social health is so complicated that it is like seeing an elephant in the dark; that is, with the term social health, go to anyone who claims to be working in this field and ask him for a definition, and he will define something for you" (Participant 2). Another added, "Various factors affect health, and social factors consist more than seventy-five percent of the factors" (Participant 9).
.PNG)
Policy stream
Public participation is a fundamental principle of PHC. Additionally, there are laws in the country that emphasize the social dimension of health. Semans, acting as intermediaries between the people and the government, can utilize this capacity effectively.
One participant explained, "The laws promulgated by the Supreme Leader regarding health and the laws related to 5-year plans and the approvals of the Supreme Health Council include many items about social health and paying attention to social factors affecting health" (Participant 8).
Another participant highlighted the importance of social partnerships: "We say that seventy-five percent of health issues are outside the management of the health system. This is either formed in the form of social partnerships or inter-sectoral cooperation. If we want to address the issue of social partnerships, the role of people will be vital. This role is important for the health of family members, fellow citizens, and their fellow citizens. Certainly, the role of the people is influential. If people want to have an effective role, they must be organized. This organization can be effective in the form of people's organizations" (Participant 6).
Participants also noted the role of Non-Governmental Organizations (NGOs) in mitigating social and health harms." NGOs mediate between the government and the people" (Participant 13). Another participant stated, "In the modern era when it seems that the role of governments has been weakened and civil institutions have become stronger, semans are one of the most important pillars of improving the health system in societies. These institutions are very effective because they are not completely non-profit and have sustainable relations with the centers of bureaucratic power. Therefore, they can convey the concerns of society to the policymakers. The existential philosophy of semans is to reduce the social harms of society and consequently improve the level of health through direct interactions with society" (Participant 4).
Political stream
The political structure of governments significantly influences their interest in social participation. During the tenure of the then-president, there was increased attention to social issues. With the beginning of the 11th government, a social department was formed within the Ministry of Health, and the General Department of NGOs was established.
Participant 1 noted, "At different times, depending on the political structure, the governments that were interested in social issues paid attention to semans, but the work was weakened in the governments that were not interested. In the first government of Dr Rouhani, social issues were given attention, and the Ministry of Health accepted that the social sphere should act independently and formed a social deputy. This social sphere was formed, and other semans and other social spheres tried to communicate, but in the following governments, this work was weakened or changed its form."
Another participant stated, "The cooperation between the health sector of the Ministry of Health and NGOs regarding health services started when the Social Affairs Department was created. Before that, these services were not very structured. This is due to our managers' views. They disagreed or didn't have enough knowledge, but the semans were doing their work. Since the appointment of this deputy, a close relationship has been established between the Ministry of Health and the semans. From my point of view, they are doing the incomplete work of the Ministry of Health" (Participant 14).
Participant 4 emphasized the significance of the Social Vice-Chancellor's establishment: "With the formation of the Social Vice-Chancellor of the Ministry of Health in 2016, a very fundamental step was taken in the field of social health. The texts always mentioned the role of 75% of psychosocial components in health. This action conveyed to society that social issues were a priority in health."
Opening the window of opportunity
According to Kingdon's theory, the convergence of the three streams-problem, solution, and political determination-creates a window of opportunity, enabling policymakers to place a policy on the agenda. If any of these streams encounter issues, the policy may not be included on the agenda. In this study, the policy window opened through the intersection of these three currents.
Participant 4 explained, "A clinical-oriented view has always prevailed in the Ministry of Health. The establishment of the social deputy and the support of the then Minister of Health for the goals of this deputy was able to create organizational legitimacy and bring social issues to the attention of senior managers of the Ministry of Health."
Closing the window of opportunity
However, changes in the Ministry of Health led to the dissolution of the Social Affairs Vice-Presidency, weakening semans' policies aimed at promoting social health.
Participant 3 described the shift: "The new Minister of Health was convinced that the organization of the social deputy is redundant. He said that we should socialize all of our deputies, but this did not happen, and all the deputies of the Ministry of Health were not socialized. The previous structure was destroyed. The structure of the social deputy was also destroyed, and only the general administration of charities and non-governmental organizations remains, which is not very active now."
Participant 9 lamented, "Unfortunately, with the change of the Ministry of Health, the new minister dissolved this whole organization and violated all the laws. This helpful structure, taken from the Thai experience, was weakened and disappeared, and now we have small centers in some places."
Participant 12 added, "Until the end of 1997, there was a social deputy. Our decisions in the country depend to a large extent on individuals. The new minister did not believe in the social deputy. The social deputy was dissolved. It was not, and other areas were affected and were either dissolved or returned to their previous positions in the social department."
Discussion
According to Kingdon's theory, for policies to be placed on the agenda, the convergence of three streams-problem, solution, and political determination-must occur to open the window of opportunity. If any of these streams encounter issues, a policy may be proposed but not included on the agenda (23). Based on the study's results, implementing social health policies can be explained using Kingdon's multiple streams model, indicating that policy changes arise from integrating these three streams.
Problem stream (First stream)
The problem stream highlights that the primary issue in policy-making for social health is the lack of a clear definition of social health agreed upon by all stakeholders. The field of social health is inherently complex and multidimensional, influenced by the diverse roles, duties, and social activities of society's members. Unfortunately, these concepts have not been adequately clarified for the managers of the Ministry of Health, brokers, and semans, making it challenging to implement effective plans without proper definitions and clarifications. A specific definition of social health and its dimensions is necessary for planning to improve social health. However, social issues are broad, and their dimensions can only be identified according to the study's time, place, and subject (24).
Amini Rarani et al. demonstrated that social health is a complex subject with no formal definition in the literature (25). Similarly, Khanjani et al. found no theoretical agreement on social issues, with various thinkers and experts using different terms to define them (26). The lack of documents and varied approaches to assessing social health in Iran (Perceived and objective social health) makes determining the state of social health challenging (27,28). This study underscores the critical role social factors play in health. Marandi's review study concluded that biological and genetic factors account for only 15% of health outcomes, the health system about 25%, and social factors about 50% (In some studies, 75%). Marandi emphasized addressing social factors to ensure health justice (29).
Policy stream (Second stream)
The policy stream proposes Public participation as a fundamental PHC Principle. The history of community participation as a vital factor in health promotion dates back to the "Alma Ata" declaration about four decades ago (30). This issue has remained significant and is now recognized as crucial for promoting health worldwide, especially among vulnerable and deprived populations (31). Brazil's "Health Council" program provides clear guidelines for public participation at the community level (32). Thailand's National Health Assembly promotes understanding among stakeholders through respectful dialogue to achieve health justice. Different stakeholders engage in discussions to reach a consensus (33).
Various laws in the country emphasize the social dimension of health. The 25th principle of the constitution highlights the importance of public cooperation and participation in decision-making, planning, and supervising the administration of the country's affairs. Keywords such as "council," "participation," and "public participation" in the country's development programs indicate the intent to involve the public in the administration of the country's affairs. In the health field, the Supreme Council of Health and Food Security, created during the fourth development plan, became a permanent body in the fifth plan. The High Council of Health Insurance in the Fifth Development Plan reviews the relative value and determines annual tariffs for healthcare services. However, the dominant approach has been to attract financial participation, aligning with only a part of the provisions in the twenty-ninth principle of the Constitution (34).
The study also highlights that semans, as intermediaries between people and governments, can be leveraged to strengthen the health system. The participation of NGOs can lead to a more efficient, equitable, and well-managed healthcare system, ultimately improving health system performance (35-37). However, NGOs face challenges in various areas, including financing, financial management, human resource management, resource mobilization, networking, government support, access to information, and strategic planning (38).
Political stream (Third stream)
The third stream, the political stream (Political determination), began with establishment of the Social Vice-Chancellor in the Ministry of Health, and the General Administration of NGOs was launched. Without determination and political support, fundamental changes in social processes are elusive. The World Health Organization has emphasized the necessity of political support and commitment, highlighting this twenty-five years after the Alma-Ata Conference, particularly for the success and future of healthcare in the Middle East and Eastern Mediterranean countries (39).
According to the results of the present study, political determination commenced with the 11th government and the commitment of the then Minister of Health, leading to the creation of the social deputy. This opened the policy window through the intersection of the three streams discussed earlier. However, the dissolution of the Social Affairs Department in the Ministry of Health subsequently closed this window of opportunity.
Study limitations
This study has several limitations, one of which pertains to Kingdon's framework. While the framework emphasizes the need to link the three streams, it does not specify the conditions under which solutions to problems are sought. Additionally, the framework overly emphasizes individual behavior while underestimating the role of institutional structures (40). Kingdon's model also has ambiguities regarding the role of entrepreneurs when policy windows open and cannot adequately explain simultaneous interactions (41).
Despite our efforts to ensure diverse samples, this qualitative study was conducted with a limited, purposefully selected sample, which restricts the generalizability of the findings. Another limitation was the difficulty in reaching some participants, largely mitigated through continuous follow-up and emphasizing the study's importance.
Conclusion
Despite the significance of social health policies and the existence of upstream laws for their implementation, these policies were not successfully implemented due to the complexity and multi-dimensionality of the social health field and a lack of interest from the authorities. The establishment of the Social Department in the Ministry of Health during the 11th government, alongside the formation of the General Administration of NGOs, created a policy window through the intersection of problem, policy, and political streams. However, with the change in the Minister of Health, the Vice-President of Social Affairs was dissolved, closing the political window.
Promoting social health is not solely the responsibility of one department; it requires the participation of experts from government, non-government, and private sectors. The Ministry of Health's policymaker and supervisor role is crucial. A specific trustee should be appointed at the Ministry of Health level to attract comprehensive support and inter-sectoral leadership. Social health indicators should be monitored and promoted through effective inter-sectoral measures to enhance healthy social behaviors across different social groups.
Acknowledgement
The authors would like to thank all the participants who made this study possible.
Funding sources
The author provided the financial resources for this study.
Ethical statement
The Golestan University of Medical Sciences Ethics Committee approved this study's protocol (IR.GOUMS.REC.1401.116).
Conflicts of interest
The author declares no conflict of interest concerning all aspects of this research.
Author contributions
Sajjad PourBagher: Research design, data collection, data analysis, review, and editing of the final version of the article. Abdulreza Bai: Initial and final drafting of the manuscript. Alireza Heidari: Data analysis, review, and editing of the article's final version.
Problem stream
The primary issue in policy-making for social health is the absence of a clear definition of social health that all stakeholders accept. The field of social health is inherently complex and multidimensional, with significant differences in the roles, duties, and social activities of society's members. Unfortunately, the Ministry of Health managers, brokers, and agents are often not adequately informed about these aspects. Social factors significantly impact health.
One participant noted, "The field of social health is so complicated that it is like seeing an elephant in the dark; that is, with the term social health, go to anyone who claims to be working in this field and ask him for a definition, and he will define something for you" (Participant 2). Another added, "Various factors affect health, and social factors consist more than seventy-five percent of the factors" (Participant 9).
Policy stream
Public participation is a fundamental principle of PHC. Additionally, there are laws in the country that emphasize the social dimension of health. Semans, acting as intermediaries between the people and the government, can utilize this capacity effectively.
One participant explained, "The laws promulgated by the Supreme Leader regarding health and the laws related to 5-year plans and the approvals of the Supreme Health Council include many items about social health and paying attention to social factors affecting health" (Participant 8).
Another participant highlighted the importance of social partnerships: "We say that seventy-five percent of health issues are outside the management of the health system. This is either formed in the form of social partnerships or inter-sectoral cooperation. If we want to address the issue of social partnerships, the role of people will be vital. This role is important for the health of family members, fellow citizens, and their fellow citizens. Certainly, the role of the people is influential. If people want to have an effective role, they must be organized. This organization can be effective in the form of people's organizations" (Participant 6).
Participants also noted the role of Non-Governmental Organizations (NGOs) in mitigating social and health harms." NGOs mediate between the government and the people" (Participant 13). Another participant stated, "In the modern era when it seems that the role of governments has been weakened and civil institutions have become stronger, semans are one of the most important pillars of improving the health system in societies. These institutions are very effective because they are not completely non-profit and have sustainable relations with the centers of bureaucratic power. Therefore, they can convey the concerns of society to the policymakers. The existential philosophy of semans is to reduce the social harms of society and consequently improve the level of health through direct interactions with society" (Participant 4).
Political stream
The political structure of governments significantly influences their interest in social participation. During the tenure of the then-president, there was increased attention to social issues. With the beginning of the 11th government, a social department was formed within the Ministry of Health, and the General Department of NGOs was established.
Participant 1 noted, "At different times, depending on the political structure, the governments that were interested in social issues paid attention to semans, but the work was weakened in the governments that were not interested. In the first government of Dr Rouhani, social issues were given attention, and the Ministry of Health accepted that the social sphere should act independently and formed a social deputy. This social sphere was formed, and other semans and other social spheres tried to communicate, but in the following governments, this work was weakened or changed its form."
Another participant stated, "The cooperation between the health sector of the Ministry of Health and NGOs regarding health services started when the Social Affairs Department was created. Before that, these services were not very structured. This is due to our managers' views. They disagreed or didn't have enough knowledge, but the semans were doing their work. Since the appointment of this deputy, a close relationship has been established between the Ministry of Health and the semans. From my point of view, they are doing the incomplete work of the Ministry of Health" (Participant 14).
Participant 4 emphasized the significance of the Social Vice-Chancellor's establishment: "With the formation of the Social Vice-Chancellor of the Ministry of Health in 2016, a very fundamental step was taken in the field of social health. The texts always mentioned the role of 75% of psychosocial components in health. This action conveyed to society that social issues were a priority in health."
Opening the window of opportunity
According to Kingdon's theory, the convergence of the three streams-problem, solution, and political determination-creates a window of opportunity, enabling policymakers to place a policy on the agenda. If any of these streams encounter issues, the policy may not be included on the agenda. In this study, the policy window opened through the intersection of these three currents.
Participant 4 explained, "A clinical-oriented view has always prevailed in the Ministry of Health. The establishment of the social deputy and the support of the then Minister of Health for the goals of this deputy was able to create organizational legitimacy and bring social issues to the attention of senior managers of the Ministry of Health."
Closing the window of opportunity
However, changes in the Ministry of Health led to the dissolution of the Social Affairs Vice-Presidency, weakening semans' policies aimed at promoting social health.
Participant 3 described the shift: "The new Minister of Health was convinced that the organization of the social deputy is redundant. He said that we should socialize all of our deputies, but this did not happen, and all the deputies of the Ministry of Health were not socialized. The previous structure was destroyed. The structure of the social deputy was also destroyed, and only the general administration of charities and non-governmental organizations remains, which is not very active now."
Participant 9 lamented, "Unfortunately, with the change of the Ministry of Health, the new minister dissolved this whole organization and violated all the laws. This helpful structure, taken from the Thai experience, was weakened and disappeared, and now we have small centers in some places."
Participant 12 added, "Until the end of 1997, there was a social deputy. Our decisions in the country depend to a large extent on individuals. The new minister did not believe in the social deputy. The social deputy was dissolved. It was not, and other areas were affected and were either dissolved or returned to their previous positions in the social department."
Discussion
According to Kingdon's theory, for policies to be placed on the agenda, the convergence of three streams-problem, solution, and political determination-must occur to open the window of opportunity. If any of these streams encounter issues, a policy may be proposed but not included on the agenda (23). Based on the study's results, implementing social health policies can be explained using Kingdon's multiple streams model, indicating that policy changes arise from integrating these three streams.
Problem stream (First stream)
The problem stream highlights that the primary issue in policy-making for social health is the lack of a clear definition of social health agreed upon by all stakeholders. The field of social health is inherently complex and multidimensional, influenced by the diverse roles, duties, and social activities of society's members. Unfortunately, these concepts have not been adequately clarified for the managers of the Ministry of Health, brokers, and semans, making it challenging to implement effective plans without proper definitions and clarifications. A specific definition of social health and its dimensions is necessary for planning to improve social health. However, social issues are broad, and their dimensions can only be identified according to the study's time, place, and subject (24).
Amini Rarani et al. demonstrated that social health is a complex subject with no formal definition in the literature (25). Similarly, Khanjani et al. found no theoretical agreement on social issues, with various thinkers and experts using different terms to define them (26). The lack of documents and varied approaches to assessing social health in Iran (Perceived and objective social health) makes determining the state of social health challenging (27,28). This study underscores the critical role social factors play in health. Marandi's review study concluded that biological and genetic factors account for only 15% of health outcomes, the health system about 25%, and social factors about 50% (In some studies, 75%). Marandi emphasized addressing social factors to ensure health justice (29).
Policy stream (Second stream)
The policy stream proposes Public participation as a fundamental PHC Principle. The history of community participation as a vital factor in health promotion dates back to the "Alma Ata" declaration about four decades ago (30). This issue has remained significant and is now recognized as crucial for promoting health worldwide, especially among vulnerable and deprived populations (31). Brazil's "Health Council" program provides clear guidelines for public participation at the community level (32). Thailand's National Health Assembly promotes understanding among stakeholders through respectful dialogue to achieve health justice. Different stakeholders engage in discussions to reach a consensus (33).
Various laws in the country emphasize the social dimension of health. The 25th principle of the constitution highlights the importance of public cooperation and participation in decision-making, planning, and supervising the administration of the country's affairs. Keywords such as "council," "participation," and "public participation" in the country's development programs indicate the intent to involve the public in the administration of the country's affairs. In the health field, the Supreme Council of Health and Food Security, created during the fourth development plan, became a permanent body in the fifth plan. The High Council of Health Insurance in the Fifth Development Plan reviews the relative value and determines annual tariffs for healthcare services. However, the dominant approach has been to attract financial participation, aligning with only a part of the provisions in the twenty-ninth principle of the Constitution (34).
The study also highlights that semans, as intermediaries between people and governments, can be leveraged to strengthen the health system. The participation of NGOs can lead to a more efficient, equitable, and well-managed healthcare system, ultimately improving health system performance (35-37). However, NGOs face challenges in various areas, including financing, financial management, human resource management, resource mobilization, networking, government support, access to information, and strategic planning (38).
Political stream (Third stream)
The third stream, the political stream (Political determination), began with establishment of the Social Vice-Chancellor in the Ministry of Health, and the General Administration of NGOs was launched. Without determination and political support, fundamental changes in social processes are elusive. The World Health Organization has emphasized the necessity of political support and commitment, highlighting this twenty-five years after the Alma-Ata Conference, particularly for the success and future of healthcare in the Middle East and Eastern Mediterranean countries (39).
According to the results of the present study, political determination commenced with the 11th government and the commitment of the then Minister of Health, leading to the creation of the social deputy. This opened the policy window through the intersection of the three streams discussed earlier. However, the dissolution of the Social Affairs Department in the Ministry of Health subsequently closed this window of opportunity.
Study limitations
This study has several limitations, one of which pertains to Kingdon's framework. While the framework emphasizes the need to link the three streams, it does not specify the conditions under which solutions to problems are sought. Additionally, the framework overly emphasizes individual behavior while underestimating the role of institutional structures (40). Kingdon's model also has ambiguities regarding the role of entrepreneurs when policy windows open and cannot adequately explain simultaneous interactions (41).
Despite our efforts to ensure diverse samples, this qualitative study was conducted with a limited, purposefully selected sample, which restricts the generalizability of the findings. Another limitation was the difficulty in reaching some participants, largely mitigated through continuous follow-up and emphasizing the study's importance.
Conclusion
Despite the significance of social health policies and the existence of upstream laws for their implementation, these policies were not successfully implemented due to the complexity and multi-dimensionality of the social health field and a lack of interest from the authorities. The establishment of the Social Department in the Ministry of Health during the 11th government, alongside the formation of the General Administration of NGOs, created a policy window through the intersection of problem, policy, and political streams. However, with the change in the Minister of Health, the Vice-President of Social Affairs was dissolved, closing the political window.
Promoting social health is not solely the responsibility of one department; it requires the participation of experts from government, non-government, and private sectors. The Ministry of Health's policymaker and supervisor role is crucial. A specific trustee should be appointed at the Ministry of Health level to attract comprehensive support and inter-sectoral leadership. Social health indicators should be monitored and promoted through effective inter-sectoral measures to enhance healthy social behaviors across different social groups.
Acknowledgement
The authors would like to thank all the participants who made this study possible.
Funding sources
The author provided the financial resources for this study.
Ethical statement
The Golestan University of Medical Sciences Ethics Committee approved this study's protocol (IR.GOUMS.REC.1401.116).
Conflicts of interest
The author declares no conflict of interest concerning all aspects of this research.
Author contributions
Sajjad PourBagher: Research design, data collection, data analysis, review, and editing of the final version of the article. Abdulreza Bai: Initial and final drafting of the manuscript. Alireza Heidari: Data analysis, review, and editing of the article's final version.
Type of Article: Original article |
Subject:
Health
Received: 2023/10/21 | Accepted: 2024/01/14 | Published: 2024/01/30
Received: 2023/10/21 | Accepted: 2024/01/14 | Published: 2024/01/30
References
1. Safari K, Bastani S, Mansourian Ravandi F. Explaining the relationship between gender identity and social health of young men and women in Tehran. Ferdowsi Univ Mashhad J Soc Sci. 2014;11(2):163-87. [View at Publisher] [DOI]
2. Hassanpour T, Hosseini M, Ghobadpour H, Sharifi M. Indicators of Social Health Promotion. Iran J Cult Health Promot. 2021;5(1):83-87. [View at Publisher] [Google Scholar]
3. Moosavi M, Shinai MS, Fateminia S, Omidnia S. Conceptual development of social capital with social health approach. Social Welfare. 2015;15(57):109-48. [View at Publisher] [Google Scholar]
4. Holt-Lunstad J. Why social relationships are important for physical health: a systems approach to understanding and modifying risk and protection. Ann Rev Psychol. 2018;69:437-58. [View at Publisher] [DOI] [PMID] [Google Scholar]
5. Holt-Lunstad J, Smith TB, Baker M, Harris T, Stephenson D. Loneliness and social isolation as risk factors for mortality: a meta-analytic review. Perspect Psychol Sci. 2015;10(2):227-37. [View at Publisher] [DOI] [PMID] [Google Scholar]
6. Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: a meta-analytic review. PLoS Med. 2010;7:e1000316. [View at Publisher] [DOI] [PMID] [Google Scholar]
7. Pantell M, Rehkopf D, Jutte D, Syme SL, Balmes J, Adler N. Social isolation: a predictor of mortality comparable to traditional clinical risk factors. Am J Public Health. 2013;103:2056-62. [View at Publisher] [DOI] [PMID] [Google Scholar]
8. Steptoe A, Shankar A, Demakakos P, Wardle J. Social isolation, loneliness, and all-cause mortality in older men and women. Proc Natl Acad Sci. 2013;110:5797-801. [View at Publisher] [DOI] [PMID] [Google Scholar]
9. Valtorta NK, Kanaan M, Gilbody S, Ronzi S, Hanratty B. Loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies. Heart. 2016;102(3):1009-16. [View at Publisher] [DOI] [PMID] [Google Scholar]
10. Holt-Lunstad J, Steptoe A. Social isolation: an underappreciated determinant of physical health. Curr Opin Psychol. 2022;43:232-7. [View at Publisher] [DOI] [PMID] [Google Scholar]
11. Wilson RS, Capuano AW, Sampaio C, Leurgans SE, Barnes LL, Farfel JM, et al. The link between social and emotional isolation and dementia in older black and white Brazilians. Int Psychogeriatr. 2021;33:1-7. [View at Publisher] [DOI] [PMID] [Google Scholar]
12. Edrisi A, Sheykhdadzadeh L, Bozorgari M. Religions rules and institution have huge responsibility in improving cultural and moral standards of the society. JMCIRI. 2016;34(3):215-32. [View at Publisher]
13. Damari B, Nasehei A, Vosoogh Moghaddam A. What should we do for improving Iranian social health? Situational analysis, national strategies and role of ministry of health and medical education. SJSPH. 2013;11(1):45-58. [View at Publisher] [Google Scholar]
14. Robinson SE, Eller WS. Participation in policy streams: Testing the separation of problems and solutions in subnational policy systems. Policy Studies J. 2010;38(2):199-216. [View at Publisher] [DOI] [Google Scholar]
15. Heidari A, Arab M, Damari B. A policy analysis of the national phenylketonuria screening program in Iran. BMC Health Serv Res. 2021;21(1):120. [View at Publisher] [DOI] [PMID] [Google Scholar]
16. Kabir M J, Heidari A, Honarvar M R, Khatirnamani Z. Analysis of electronic referral system agenda setting based on kingdon multiple streams framework. Payesh. 2022;21(1):25-33. [View at Publisher] [DOI] [Google Scholar]
17. Heidari A, Arab M, Etemad K, Damari B, Lotfi M. National Phenylketonuria Screening Program in Iran; Why and How. Scientific Journal of School of Public Health and Institute of Public Health Research. 2018;16(2):148-63. [View at Publisher] [Google Scholar]
18. Amini rarani M, Asadi L. The process of domestic violence agenda setting in the corona pandemic: an application of Kingdon Multiple Streams Model. Nursing and Midwifery Journal. 2021;19(9):752-76. [View at Publisher] [DOI] [Google Scholar]
19. Pourbagher S, Bay A, Heidari A. Challenges of Non-Governmental Organizations to Promote Social Health in Iran: A Qualitative Study. J Gorgan Univ Med Sci. 2023;25(2):92-102. [View at Publisher] [Google Scholar]
20. Etemad K, Heidari A, Panahi MH, Lotfi M, Fallah F, Sadeghi S. Challenges of Access to Data of Ministry of Health from the Perspective of Policy-makers, Producers, and Consumers of Data: A Qualitative Study. Iran J Epidemiol. 2017;13(3):174-82. [View at Publisher] [Google Scholar]
21. Damari B, Heidari A, Rahbari Bonab M, Vosoogh Moghadam A. Designing a toolkit for the assessment of health in all policies at a national scale in Iran. Health Promot Perspect. 2020;10(3):244-9. [View at Publisher] [DOI] [PMID] [Google Scholar]
22. Heidari A, Arab M, Etemad K, Damari B. Challenges of implementation of the national Phenylketonuria screening program in Iran: a qualitative study. Electronic physician. 2016;8(10):3048. [View at Publisher] [DOI] [PMID] [Google Scholar]
23. Sabatier PA. Theories of the policy process. New YOrk: Westview Press; 2007. [View at Publisher] [DOI] [Google Scholar]
24. Nooraie H, Tabibian M, Rezaie N. The Analysis of Security in Informal Areas with Special Reference to Social Pathologies (Case study: Khaksefid-Tehran). Hoviateshahr. 2013;7(13):11-22. [View at Publisher] [DOI] [Google Scholar]
25. Rarani MA, Rafiye H, Morasae EK. Social health status in Iran: an empirical study. Iran J Public Health. 2013;42(2):206-14. [View at Publisher] [Google Scholar]
26. Khanjankhani Kh, Kiani MM, Mohamadi E, Olyaeimanesh A, Takian A. An Introductory Remark into the Terminology of Social Problems and the Health System. Iran J Cult Health Promot. 2020;4(2):123-30. [View at Publisher]
27. Abachizadeh K, Omidnia S, Hajebi A, Asadi A, RassouliM, Leila B. Measuring self-rated social health of Iranians: a population-based survey in three cities. Novelty Biomed. 2014;2(3):79-84. [View at Publisher] [DOI] [Google Scholar]
28. Khalooei A, Karamatili SM. Social health and its related factors among medical students of Kerman University of Medical Sciences in 2017. Commun Health. 2018;5(4):355-65. [View at Publisher] [Google Scholar]
29. Marandi SA. Social Determinants of Health. Iran J Cult Health Promot. 2020;4(2):131-140. [View at Publisher]
30. WHO. Declaration of Alma-Ata. Geneva: World Health Organization; 1978. [View at Publisher] [Google Scholar]
31. Rifkin SB. Lessons from community participation in health programmes: a review of the post Alma-Ata experience. Int Health. 2009;1(1):31-6. [View at Publisher] [DOI] [PMID] [Google Scholar]
32. Kohler JC, Martinez MG. Participatory health councils and good governance: healthy democracy in Brazil? Int J Equity Health. 2015;14. [View at Publisher] [DOI] [PMID] [Google Scholar]
33. Rajan D, Mathurapote N, Putthasri W, Posayanonda T, Pinprateep P, de Courcelles S, Bichon R, Ros E, Delobre A, Schmets G. Institutionalizing participatory health governance: lessons from nine years of the National Health Assembly model in Thailand. BMJ Glob Health. 2019;10;4(Suppl 7): e001769. [View at Publisher] [DOI] [PMID] [Google Scholar]
34. Rahbari Bonab M, Majdzadeh R, Rajabi F, Vedadhir A. Participatory Health Policy-Making in IRAN: Reflection on the Experience after the Revolution, within the Legal Pyramid Framework. Iran J Cult Health Promot. 2022;6(1):110-17. [View at Publisher] [Google Scholar]
35. Pfeiffer J. International NGOs and primary health care in Mozambique: the need for a new model of collaboration. Soc Sci Med. 2003;56(4):725-38. [View at Publisher] [DOI] [PMID] [Google Scholar]
36. Ejaz I, Shaikh BT, Rizvi N. NGOs and government partnership for health systems strengthening: a qualitative study presenting viewpoints of government, NGOs and donors in Pakistan. BMC Health Serv Res. 2011;11:1-7. [View at Publisher] [DOI] [PMID] [Google Scholar]
37. Sanadgol A, Doshmangir L, Khodayari-Zarnaq R, Sergeevich Gordeev V. Role of non-governmental organizations in moving toward universal health coverage: A case study in Iran. Front. Public Health. 2022;10:985079. [View at Publisher] [DOI] [PMID] [Google Scholar]
38. Sanadgol A, Doshmangir L, Majdzadeh R, Gordeev VS. Strategies to strengthen non-governmental organizations' participation in the Iranian health system. Front Public Health. 2022;10:929614. [View at Publisher] [DOI] [PMID] [Google Scholar]
39. World Health Organization. Regional Committee for the Eastern Mediterranean. Primary health care: 25 years after Alma-Ata. 2003. [View at Publisher] [Google Scholar]
40. Zachariadis N. The multiple streams framework: Structure, limitations, prospects. Theories of the policy process. 2nd ed. Westview Press: Boulder; 2007. p.65-92. [View at Publisher] [DOI] [Google Scholar]
41. Khodayari-Zarnaq R, Ravaghi H, Mosaddeghrad A, Sedaghat A, Mohraz M. HIV/AIDS policy agenda setting in Iran. Med J Islam Repub Iran. 2016;30:392. [View at Publisher] [Google Scholar]
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