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Khanjankhani K, Takian A, Mohammadi S, Shamsi Gooshkih E. Conflict of Interest in the Governance of Healthcare System in Iran: Root Causes, Challenges, and Solutions (A Qualitative Study). jha 2025; 28 (1) :76-94
URL: http://jha.iums.ac.ir/article-1-4607-en.html
URL: http://jha.iums.ac.ir/article-1-4607-en.html
1- Non-communicable Diseases Research Institute, Shahid Sadoughi University of Medical Sciences,Yazd, Iran. & Department of Global Health and Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
2- Health Equity Research Centre, Tehran University of Medical Sciences, Tehran, Iran. & Center of Excellence for Global Health, Department of Global Health and Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. ,takian@tums.ac.ir
3- Public Health Law Group, The Institute for Legal Innovations, Tehran, Iran. & Center of Think Tank for Good Governance in Health, Tehran University of Medical Sciences, Tehran, Iran.
4- Research Center for Medical Ethics and History, Tehran University of Medical Sciences, Iran. & Monash Bioethics Center, Monash University, Australia.
2- Health Equity Research Centre, Tehran University of Medical Sciences, Tehran, Iran. & Center of Excellence for Global Health, Department of Global Health and Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. ,
3- Public Health Law Group, The Institute for Legal Innovations, Tehran, Iran. & Center of Think Tank for Good Governance in Health, Tehran University of Medical Sciences, Tehran, Iran.
4- Research Center for Medical Ethics and History, Tehran University of Medical Sciences, Iran. & Monash Bioethics Center, Monash University, Australia.
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Table1. Thematic structure of challenges and solutions in managing conflicts of interest in Iran’s healthcare system governance
Managing personal COI: Appointing non-physicians to policy roles, imposing post-employment restrictions, and monitoring former officials help curb personal COI [37, 38]. For example, in China, former officials are banned from holding related profit-making roles for three years [39]. Addressing the financial well-being of officials reduces the risk of corruption [40, 41].
Role of civil institutions, media, and broadcasting: Civil institutions and media drive accountability and awareness [16]. Free media must avoid COI, as journalists may develop biases toward gift-giving entities [42, 43]. Strengthening civil society’s monitoring capacity requires public awareness campaigns [16].
Limitations
A key limitation was the difficulty in obtaining candidate information from participants, particularly those potentially involved in COI situations. These participants tended to provide general opinions rather than detailed information for realities within Iran’s healthcare system. To mitigate this, diverse participants were selected based on organizational position, expertise, and managerial experience, ensuring the capture of more varied, and realistic perspectives. However, potential response bias cannot be entirely ruled out.
Conclusion
Cultural, political, managerial, and regulatory contexts drive COI in Iran’s healthcare system, making culturally and politically sensitive management strategies essential. Challenges include contextual, managerial, and policy-related obstacles; however, solutions such as structural reforms, enhanced policy-making, robust regulations, and empowered civil institutions are effective. Despite its limitations, this study provides actionable insights for effective COI management.
Declerations
Ethical considerations: This article is a part of the thesis titled “Analysis for Policy for Managing Conflict of Interest in the Health System Governance of Iran”, for the PhD degree in Health Policy approved by Tehran University of Medical Sciences in 2019 with this ethical code: IR.TUMS.PHS.REC.1398.152.
Funding: None
Conflicts of interests: The authors declare that they have no competing interests.
Authors’ contribution: A.T (corresponding author): Conceptualization, supervision; Kh.Kh: methodology, data management, data analysis, writing; SM: Writing-review & editing; E.Sh: Writing- review & editing. All authors have read and approved the final text of the article.
Consent for publication: None
Data availability: Due to the confidentiality of interviews, data cannot be shared.
AI deceleration: To search for relevant literature, the authors employed AI-based tools including Semantic Scholar and Epsilon AI.
Acknowledgements: The authors are grateful to all the people who helped in this research.
Full-Text: (441 Views)
Introduction
Policymakers in governmental positions are inevitably exposed to various financial and social interests that affect various aspects of their lives, as well as official and unofficial groups, associations, and other social affiliations. Conflict of interest (COI) situations have the potential to lead to corruption; hence, there is a need to identify these situations and develop solutions for their management [1]. Previous evidence indicates that all aspects of healthcare systems are susceptible to COI situations. One research demonstrated that the amalgamation of roles in oversight, financial provision, and service delivery within the healthcare system has led to the creation of various COI situations in Iran [2]. The Research Center of the Parliament of Iran identified COI situations in the payment system, tariff determination for the private sector, and complaint handling against physicians by the medical system, as well as in the activities of senior managers at the Ministry of Health & Medical Education (MoHME), as the most significant COI situations in Iran healthcare system [3].
Management solutions for COI situations are not feasible without considering the social interactions among healthcare system stakeholders. Therefore, instead of efforts to eliminate these situations, it may be more effective to manage them in a way that stops corruption, maintains public trust, and utilizes educational mechanisms for performance transparency, and legal behavior reforms [4-6]. Studies on COI in the Iranian healthcare system have mostly focused on ethical implications, the role of COI in physicians’ decisions, and its impact on research outcomes. Little evidence exists on identifying key areas, challenges, and solutions for COI management [5-8]. Considering the importance of managing COI situations in the healthcare system, this study aimed to identify the challenges and potential solutions for managing COI situations in the Iranian healthcare system.
Methods
This study was conducted using a qualitative approach. We interviewed 50 purposefully-selected health experts, including former senior managers, and specialists in medical ethics and health policy, with expertise in the research subject. We selected participants from a diverse range of organizations, including Parliament, National Institutes of Health Research, Food and Drug Organization, insurance organizations, the Medical and Nursing Councils, the universities of medical sciences (UMSs), the
Ministry of Health and Medical Education (MoHME), the Welfare Organization, municipalities, pharmaceutical and medical equipment companies, and other relevant sectors.
Initially, we created a list of eligible participants based on relevance and expertise. After making the necessary arrangements, we sent interview invitations. Only one expert declined to participate. Two researchers (K.K. and A.T.) conducted all interviews. Before each interview, participants received the interview guide and an explanation of the study’s objectives via email or messaging platforms. We used a semi-structured interview guide that initially contained eight questions. The guide was pilot-tested with five participants and revised based on their feedback to enhance clarity and relevance, resulting in a set of five final questions. The guide covered three thematic areas: questions pertaining to the genesis of COI (one question), challenges associated with conflicts of interest in healthcare system governance (two questions), and managerial solutions (two questions).
The interviews lasted approximately 45 to 60 minutes and were mostly conducted virtually via Skype, with only three held in person. All sessions were recorded with participants' consent, and field notes were taken during the interviews. Interviews continued until data saturation was achieved, which occurred at the 50th interview. We employed a snowball sampling technique whereby, at the end of each interview, participants were asked to suggest other experts in the field.
Thematic data analysis followed an inductive framework analysis approach and was performed using ATLAS.ti version 9 software. Two researchers independently coded each transcript. After coding, team discussions were held to compare and consolidate codes and categories, reaching consensus. The research team consisted of four researchers (one female, three male), with backgrounds in health policy, health law, health services management, and medical ethics. Three of them were university faculty members. No repeat interviews were needed. To enhance trustworthiness and rigor, we used detailed description and included extensive direct quotations from participants in the final report to allow readers to understand the context and depth of the findings.
Results
Policymakers in governmental positions are inevitably exposed to various financial and social interests that affect various aspects of their lives, as well as official and unofficial groups, associations, and other social affiliations. Conflict of interest (COI) situations have the potential to lead to corruption; hence, there is a need to identify these situations and develop solutions for their management [1]. Previous evidence indicates that all aspects of healthcare systems are susceptible to COI situations. One research demonstrated that the amalgamation of roles in oversight, financial provision, and service delivery within the healthcare system has led to the creation of various COI situations in Iran [2]. The Research Center of the Parliament of Iran identified COI situations in the payment system, tariff determination for the private sector, and complaint handling against physicians by the medical system, as well as in the activities of senior managers at the Ministry of Health & Medical Education (MoHME), as the most significant COI situations in Iran healthcare system [3].
Management solutions for COI situations are not feasible without considering the social interactions among healthcare system stakeholders. Therefore, instead of efforts to eliminate these situations, it may be more effective to manage them in a way that stops corruption, maintains public trust, and utilizes educational mechanisms for performance transparency, and legal behavior reforms [4-6]. Studies on COI in the Iranian healthcare system have mostly focused on ethical implications, the role of COI in physicians’ decisions, and its impact on research outcomes. Little evidence exists on identifying key areas, challenges, and solutions for COI management [5-8]. Considering the importance of managing COI situations in the healthcare system, this study aimed to identify the challenges and potential solutions for managing COI situations in the Iranian healthcare system.
Methods
This study was conducted using a qualitative approach. We interviewed 50 purposefully-selected health experts, including former senior managers, and specialists in medical ethics and health policy, with expertise in the research subject. We selected participants from a diverse range of organizations, including Parliament, National Institutes of Health Research, Food and Drug Organization, insurance organizations, the Medical and Nursing Councils, the universities of medical sciences (UMSs), the
Ministry of Health and Medical Education (MoHME), the Welfare Organization, municipalities, pharmaceutical and medical equipment companies, and other relevant sectors.
Initially, we created a list of eligible participants based on relevance and expertise. After making the necessary arrangements, we sent interview invitations. Only one expert declined to participate. Two researchers (K.K. and A.T.) conducted all interviews. Before each interview, participants received the interview guide and an explanation of the study’s objectives via email or messaging platforms. We used a semi-structured interview guide that initially contained eight questions. The guide was pilot-tested with five participants and revised based on their feedback to enhance clarity and relevance, resulting in a set of five final questions. The guide covered three thematic areas: questions pertaining to the genesis of COI (one question), challenges associated with conflicts of interest in healthcare system governance (two questions), and managerial solutions (two questions).
The interviews lasted approximately 45 to 60 minutes and were mostly conducted virtually via Skype, with only three held in person. All sessions were recorded with participants' consent, and field notes were taken during the interviews. Interviews continued until data saturation was achieved, which occurred at the 50th interview. We employed a snowball sampling technique whereby, at the end of each interview, participants were asked to suggest other experts in the field.
Thematic data analysis followed an inductive framework analysis approach and was performed using ATLAS.ti version 9 software. Two researchers independently coded each transcript. After coding, team discussions were held to compare and consolidate codes and categories, reaching consensus. The research team consisted of four researchers (one female, three male), with backgrounds in health policy, health law, health services management, and medical ethics. Three of them were university faculty members. No repeat interviews were needed. To enhance trustworthiness and rigor, we used detailed description and included extensive direct quotations from participants in the final report to allow readers to understand the context and depth of the findings.
Results
We extracted three themes, 12 sub-categoriess, and 57 codes in this study (Table1).
Table1. Thematic structure of challenges and solutions in managing conflicts of interest in Iran’s healthcare system governance
| Theme | Sub-constructs | Code |
| Origins of COI | 1. Cultural context | 1. Unreasonable societal expectations regarding COI 2. Inadequate cultural infrastructure |
| 2. Political context | 1. Instability in political positions of managers 2. COI in decision-making mechanisms 3. COI in interdepartmental leadership |
|
| 3. Management and executive context | 1. COI in the organization objectives 2. COI in processes and tasks, and affairs implementation 3. COI in evaluation and assessment actions 4. COIs in appointments |
|
| 4. Regulatory and legal context | 1. COI in regulations, standards and guidelines formulation 2. Insufficient COI management frameworks 3. Limited involvement of regulatory mechanisms in handling COI 4. Dispersed and inefficient rules and regulations 5. Insufficient assurance in the enforcement of law |
|
| Challenges of managing COI situations | 1. Contextual challenges | 1. The integration of medical science education into healthcare service 2. The complexity and dynamics of the health system 3. The bureaucratic and structural defects in the body of the MOHME |
| 2. Management and executive challenges | 1. Failure to define official codes for managing COI 2. A purely technical look at the COI 3. Choosing improper person in decision-making positions 4. Long bureaucracies in decision-making mechanisms |
|
| 3. Policy challenges | 1. Lack of attention to managing COI by policymakers 2. Insular and short-term perspective 3. Instability in political decisions 4. Inadequate accountability for wrong decisions 5. Ignoring the governance duties of the MOHME 6. Insufficient political will to manage COI among policymakers 7. Insufficient information asymmetry between actors of COI management 8. Applying pressure by different groups and other external factors 9. COI arising from existing laws |
|
| Management solutions for COI situations | 1. Management of structural/institutional cases | 1. Modifying organizational structures and processes 2. Redefining the appointment description 3. The output quality of the activities 4. Implementation of transparency in all activities 5. Legal follow-up of the decisions made and acceptance of responsibility 6. Separating the rule maker from the enforcer of the rules |
| 2. Solutions to improve the management of COI | 1. Strengthening the political will of managers regarding the management of COI 2. Strengthening institution-building and evidence-informed decision-making mechanisms 3. Reducing the power gap between different actors and managing pressure groups 4. Removing the gun barrel and island view in policy-making and decision-making 5. Strengthening the supervisory role of the MOHME 6. Strengthening the intervention of all actors in the decision process |
|
| 3. Strengthening laws and regulatory mechanisms | 1. Strengthening and focusing on the self-regulation role of the MOHME 2. Simultaneous use of hard and soft policies 3. Separating the supervised from the supervisor 4. Managing opportunities for violations related to COIs 5. Creating legal support and formulating or amending laws 6. Applying restrictions on shareholding and voting rights 7. Monitoring by the legal system |
|
| 4. Management of personal cases | 1. Management of COI in appointed persons 2. Applying post-employment restrictions and monitoring the employee after leaving the job 3. Adopting the approach of preventing COIs in the selection of employee 4. Prohibition of simultaneous employment of government employees in private and public sectors 5. Compilation of ethical codes, culture building and training of government employee 6. Attention to the living conditions of employees |
|
| 5. The role of civil institutions, press and radio |
| 1. Demanding civil institutions, press and radio from all effective actors in the decision-making process 2. Informing society about COI and strengthening their role in its management 3. Listening to public voices and monitoring their decisions |
Discussion
In this study, three main themes were identified: origins of COI, challenges in managing COI, and management solutions.
Origins of COI: COI in Iran's healthcare system arises within cultural, political, managerial and executive, as well as regulatory and legal domains. Each is explored in detail as follows.
Cultural context: The cultural context significantly contributes to COI formation. Currently, no formal educational framework exists in Iranian organizations to address COI situations. A 2014 OECD survey highlights that training newly appointed officials enhances awareness of COI[9]. For example, the U.S. Office of Government Ethics provides advisory materials to support officials’ ethical responsibilities [10], while Argentina’s Anti-Corruption Office offers an online COI simulator for self-assessment [9]. Adopting similar educational initiatives could mitigate culturally driven COI in Iran.
Political context: Political instability fosters competition among stakeholders, increasing opportunities for COI [11]. The World Bank notes that political instability drives corruption in governance [12]. COI in intersectoral leadership can lead to decisions that are harmful to public health. Political accountability, which prioritizes citizens’ demands, is critical for legitimizing governance and ensuring realization of civic rights [13]. Enhancing political accountability could address politically driven COI.
Managerial and executive context: Managerial and executive processes, such as healthcare service accreditation, are highly susceptible to COI due to non-independent accreditation bodies and inappropriate organizational MOHME structures [14, 15]. The World Health Organization stresses the importance of understanding organizational missions to manage COI [16]. Countries such as Germany and Sweden use international accreditation institutes [17,18], while the U.S. and Canada rely on independent non-profit organizations [19, 20]. Independent accreditation could reduce managerial COI in Iran.
Regulatory and legal context: COI in developing regulations often marginalizes certain professions, such as optometry compared to ophthalmology, due to dominance of specific specialists [21]. Studies recommend excluding individuals with COI from guideline development and requiring transparent disclosure of any COI, thereby ensuring evidence-based decisions [21, 22]. Countries should establish monitoring mechanisms for policy implementation [16]. Enhancing transparency in Iran’s regulatory processes is therefore essential.
Challenges of managing COI: Managing COI is complex due to contextual, managerial, and policy-related obstacles.
Contextual challenges: The integration of medical education with healthcare governance under the Ministry of Health fosters allegiance to specific groups, leading to decisions that favor group interests rather than public goals [21]. Bureaucratic corruption erodes public trust and undermines governance stability [23, 24]. Reforms must consider systemic impacts to avoid unintended consequences.
Managerial and executive challenges: A technical approach to COI overlooks its political-social dimensions [25]. Recommendations are strengthening interest groups, combating corruption, and promoting ethical shifts in public services [26, 27]. Adopting a socio-political perspective could improve COI management in Iran.
Policy-making challenges: Policymakers often accept COI situations instead of addressing them due to short-term and fragmented perspectives on health governance [16, 28]. A lack of accountability, neglect of Ministry of Health responsibilities, and pressures from interest groups further exacerbate these issues [29, 30]. Challenging existing power dynamics is essential [31, 32] and aligning interest groups with public interests is a viable strategy.
Solutions for managing COI: Solutions span structural, institutional, individual, and societal levels, including policy-making improvements, regulatory strengthening, personal COI management, and civil institution empowerment.
Structural and institutional management: Reforming healthcare structures and separating conflicting roles are critical [33]. Transparency accelerates reforms when it is sufficient to assess severity of COI. Data-driven verification enhances transparency [9]. The Ministry of Health should prioritize governance responsibilities particularly evidence-informed policy-making [21].
Policy-making improvements: Enhancing policy-making requires political will, strong institutional frameworks, and a reduction in power disparities [34]. Key elements include evidence-informed decision-making, management of pressure groups, and strengthened accountability [21].
Strengthening regulatory mechanisms: Separating regulators from entities they observe help reduce bias [21]. Self-regulation by the Ministry of Health, with oversight by low-COI groups, is crucial. Combining hard (punitive) and soft (preventive) policies, as demonstrated in South Korea [35], is effective. Legal frameworks require ethical support to ensure compliance [36].
In this study, three main themes were identified: origins of COI, challenges in managing COI, and management solutions.
Origins of COI: COI in Iran's healthcare system arises within cultural, political, managerial and executive, as well as regulatory and legal domains. Each is explored in detail as follows.
Cultural context: The cultural context significantly contributes to COI formation. Currently, no formal educational framework exists in Iranian organizations to address COI situations. A 2014 OECD survey highlights that training newly appointed officials enhances awareness of COI[9]. For example, the U.S. Office of Government Ethics provides advisory materials to support officials’ ethical responsibilities [10], while Argentina’s Anti-Corruption Office offers an online COI simulator for self-assessment [9]. Adopting similar educational initiatives could mitigate culturally driven COI in Iran.
Political context: Political instability fosters competition among stakeholders, increasing opportunities for COI [11]. The World Bank notes that political instability drives corruption in governance [12]. COI in intersectoral leadership can lead to decisions that are harmful to public health. Political accountability, which prioritizes citizens’ demands, is critical for legitimizing governance and ensuring realization of civic rights [13]. Enhancing political accountability could address politically driven COI.
Managerial and executive context: Managerial and executive processes, such as healthcare service accreditation, are highly susceptible to COI due to non-independent accreditation bodies and inappropriate organizational MOHME structures [14, 15]. The World Health Organization stresses the importance of understanding organizational missions to manage COI [16]. Countries such as Germany and Sweden use international accreditation institutes [17,18], while the U.S. and Canada rely on independent non-profit organizations [19, 20]. Independent accreditation could reduce managerial COI in Iran.
Regulatory and legal context: COI in developing regulations often marginalizes certain professions, such as optometry compared to ophthalmology, due to dominance of specific specialists [21]. Studies recommend excluding individuals with COI from guideline development and requiring transparent disclosure of any COI, thereby ensuring evidence-based decisions [21, 22]. Countries should establish monitoring mechanisms for policy implementation [16]. Enhancing transparency in Iran’s regulatory processes is therefore essential.
Challenges of managing COI: Managing COI is complex due to contextual, managerial, and policy-related obstacles.
Contextual challenges: The integration of medical education with healthcare governance under the Ministry of Health fosters allegiance to specific groups, leading to decisions that favor group interests rather than public goals [21]. Bureaucratic corruption erodes public trust and undermines governance stability [23, 24]. Reforms must consider systemic impacts to avoid unintended consequences.
Managerial and executive challenges: A technical approach to COI overlooks its political-social dimensions [25]. Recommendations are strengthening interest groups, combating corruption, and promoting ethical shifts in public services [26, 27]. Adopting a socio-political perspective could improve COI management in Iran.
Policy-making challenges: Policymakers often accept COI situations instead of addressing them due to short-term and fragmented perspectives on health governance [16, 28]. A lack of accountability, neglect of Ministry of Health responsibilities, and pressures from interest groups further exacerbate these issues [29, 30]. Challenging existing power dynamics is essential [31, 32] and aligning interest groups with public interests is a viable strategy.
Solutions for managing COI: Solutions span structural, institutional, individual, and societal levels, including policy-making improvements, regulatory strengthening, personal COI management, and civil institution empowerment.
Structural and institutional management: Reforming healthcare structures and separating conflicting roles are critical [33]. Transparency accelerates reforms when it is sufficient to assess severity of COI. Data-driven verification enhances transparency [9]. The Ministry of Health should prioritize governance responsibilities particularly evidence-informed policy-making [21].
Policy-making improvements: Enhancing policy-making requires political will, strong institutional frameworks, and a reduction in power disparities [34]. Key elements include evidence-informed decision-making, management of pressure groups, and strengthened accountability [21].
Strengthening regulatory mechanisms: Separating regulators from entities they observe help reduce bias [21]. Self-regulation by the Ministry of Health, with oversight by low-COI groups, is crucial. Combining hard (punitive) and soft (preventive) policies, as demonstrated in South Korea [35], is effective. Legal frameworks require ethical support to ensure compliance [36].
Managing personal COI: Appointing non-physicians to policy roles, imposing post-employment restrictions, and monitoring former officials help curb personal COI [37, 38]. For example, in China, former officials are banned from holding related profit-making roles for three years [39]. Addressing the financial well-being of officials reduces the risk of corruption [40, 41].
Role of civil institutions, media, and broadcasting: Civil institutions and media drive accountability and awareness [16]. Free media must avoid COI, as journalists may develop biases toward gift-giving entities [42, 43]. Strengthening civil society’s monitoring capacity requires public awareness campaigns [16].
Limitations
A key limitation was the difficulty in obtaining candidate information from participants, particularly those potentially involved in COI situations. These participants tended to provide general opinions rather than detailed information for realities within Iran’s healthcare system. To mitigate this, diverse participants were selected based on organizational position, expertise, and managerial experience, ensuring the capture of more varied, and realistic perspectives. However, potential response bias cannot be entirely ruled out.
Conclusion
Cultural, political, managerial, and regulatory contexts drive COI in Iran’s healthcare system, making culturally and politically sensitive management strategies essential. Challenges include contextual, managerial, and policy-related obstacles; however, solutions such as structural reforms, enhanced policy-making, robust regulations, and empowered civil institutions are effective. Despite its limitations, this study provides actionable insights for effective COI management.
Declerations
Ethical considerations: This article is a part of the thesis titled “Analysis for Policy for Managing Conflict of Interest in the Health System Governance of Iran”, for the PhD degree in Health Policy approved by Tehran University of Medical Sciences in 2019 with this ethical code: IR.TUMS.PHS.REC.1398.152.
Funding: None
Conflicts of interests: The authors declare that they have no competing interests.
Authors’ contribution: A.T (corresponding author): Conceptualization, supervision; Kh.Kh: methodology, data management, data analysis, writing; SM: Writing-review & editing; E.Sh: Writing- review & editing. All authors have read and approved the final text of the article.
Consent for publication: None
Data availability: Due to the confidentiality of interviews, data cannot be shared.
AI deceleration: To search for relevant literature, the authors employed AI-based tools including Semantic Scholar and Epsilon AI.
Acknowledgements: The authors are grateful to all the people who helped in this research.
Type of Study: Research |
Subject:
Health Policy
Received: 2025/01/25 | Accepted: 2025/07/30 | Published: 2025/09/3
Received: 2025/01/25 | Accepted: 2025/07/30 | Published: 2025/09/3
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