Keywords
Stakeholder network analysis
Health governance
Equity
Iran
Abstract
Hospital beds are usually treated as little more than a headcount – a number meant to signal how ready a health system is to absorb demand. But their real functional value depends on how well they are linked to workforce, governance, and the other building blocks of the system. In Iran, national-level equity indicators look reassuring on their own (Gini coefficient ≈0.24), yet they conceal sharp sub-national disparities, with city-level inequality reaching as high as 0.68-0.70 in Shiraz. What has been missing from this literature is any account of who actually makes bed-allocation decisions, and how the relationships among these actors shape the outcomes so often described in aggregate terms.
This study combined 34 semi-structured interviews with policymakers, university leaders, and hospital managers with Social Network Analysis (SNA) to map the stakeholder network governing hospital bed allocation in Iran. The resulting network comprised 17 actors connected through 81 directed ties (density=0.298). Medical Universities showed the highest betweenness centrality (0.289), positioning them as the network’s principal structural brokers, while the Ministry of Health held the highest weighted out-degree (27), reflecting its concentrated directive influence. Political-social ties dominated the network, accounting for 43.2% of all edges, while regulatory and oversight ties were comparatively scarce (9.9%). A series of robustness checks – including sensitivity analysis across evidence thresholds and a random edge-deletion perturbation analysis with 500 iterations – confirmed that both of these central findings held up under scrutiny.
Taken together, the results suggest that Iran’s coexistence of national equity and local inequity is not merely a statistical artifact of how the data happen to be aggregated, but reflects a genuine structural problem in governance: Medical Universities, the actors best positioned to observe local need, lack authority commensurate with that position, while independent regulatory oversight remains minimal. Addressing bed-allocation inequity, then, is likely to require structural reform of decision-making authority and oversight mechanisms – not simply expanding capacity.
References
Papanicolas I, Rajan D, Karanikolos M, Soucat A, Figueras J, editors. Health system performance assessment: A framework for policy analysis. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2022.
Seixas BV, Regier DA, Bryan S, Mitton C. Describing practices of priority setting and resource allocation in publicly funded health care systems of high-income countries. BMC Health Serv Res 2021;21:90. https://doi.org/10.1186/s12913-021-06078-z.
Kroneman M, Siegers JJ. The effect of hospital beds’ reduction on the use of beds: a comparative study of 10 European countries. Soc Sci Med 2004;59:1731-40. https://doi.org/10.1016/j.socscimed.2004.01.036.
Wang Z, Dong L, Xing X, Liu Z, Zhou Y. Disparity in hospital beds allocation at the county level in China: an analysis based on a Health Resource Density Index (HRDI) model. BMC Health Serv Res 2023;23:1293. https://doi.org/10.1186/s12913-023-10266-4.
Barasa EW, Molyneux S, English M, Cleary S. Hospitals as complex adaptive systems: A case study of factors influencing priority setting practices at the hospital level in Kenya. Soc Sci Med 2017;174:104-12. https://doi.org/10.1016/j.socscimed.2016.12.026. Epub 2016 Dec 20.
Mac Conghail L, Parker S, Matthews A, Burke S. Examining the roles, relationships and power dynamics shaping universal health system policy processes in high- and upper-middle-income countries: a scoping review. BMC Health Serv Res 2025;26:4. https://doi.org/10.1186/s12913-025-13773-8.
Kwamie A, Gilson L, Compaore R, Cloete K, El-Jardali F, Shekh Mohamed I, Molyneux S, Ramani S, Schneider H, Srinivas PN, Tomson G, Tsofa B, Rasanathan K. Advancing health policy and systems research and analysis: new frontiers, renewed relevance. Health Policy Plan 2026;41:492-7. https://doi.org/10.1093/heapol/czag014.
Topp SM, Schaaf M, Sriram V, Scott K, Dalglish SL, Nelson EM, Sr R, Mishra A, Asthana S, Parashar R, Marten R, Costa JGQ, Sacks E, Br R, Reyes KAV, Singh S. Power analysis in health policy and systems research: a guide to research conceptualisation. BMJ Glob Health 2021;6:e007268. https://doi.org/10.1136/bmjgh-2021-007268.
Pyone T, Smith H, van den Broek N. Frameworks to assess health systems governance: a systematic review. Health Policy Plan 2017;32:710-22. https://doi.org/10.1093/heapol/czx007.
Haghdoost A, Hashemi H, Noori Hekmat S, Haji Aghajani M, Janbabaee G, Maher A, Janbabaee GH, Maher A, Javadi AM, Emadi S, Haghighi H, Rajabalipour MR, Dehnavieh R, Ferdosi M, RashidiNejad HR, Moeen Samadani F, Rahimisadegh R. The Geographical Distribution of Hospital Beds in Iran in 2016 and the Estimation of 2026. irje 2018;13:1-13. URL: http://irje.tums.ac.ir/article-1-5972-fa.html.
Darzi Ramandi S, Niakan L, Aboutorabi M, Javan Noghabi J, Khammarnia M, Sadeghi A. Trend of Inequality in the Distribution of Health Care Resources in Iran. Galle Med J 2016;5:e618. https://doi.org/10.31661/gmj.v5i3.618.
Behzadifar M, Shaygan F, Ebrahimi P, Shahabi S, Azari S, Teli BD, Martini M, Behzadifar M. Assessing equity in the distribution of hospital beds in Lorestan, western Iran: a regional analysis. J Prev Med Hyg 2024;65:E449-E455. https://doi.org/10.15167/2421-4248/jpmh2024.65.3.3356.
Keshvari M, Jafari M, Ravaghi H. Equity in the allocation of hospital beds in Iran: a systematic review and meta-analysis. J Prev Med Hyg 2026;67e15-e24. https://doi.org/10.82082/2421-4248/jpmh2026.67.1.3785.
Najibi SM, Seyedi SH, Farhadi P, Kharazmi E, Shojaei P, Delavari S, Lotfi F, Kavosi Z. Development of a model for predicting hospital beds shortage and optimal policies using system dynamics approach. BMC Health Serv Res 2022;22(1):1525. https://doi.org/10.1186/s12913-022-08936-w.
Najibi M, Lotfi F, Kharazmi E, Farhadi P, Shojaei P, Bastani P, Kavosi Z. Identification and Prioritization of Local Indicators of Hospital Bed Allocation in Iran 2021.
Ahmad M, Wilkins S. Purposive sampling in qualitative research: a framework for the entire journey. Qual Quant 2025;59:1461-79. https://doi.org/10.1007/s11135-024-02022-5.
Wutich A, Beresford M, Bernard HR. Sample Sizes for 10 Types of Qualitative Data Analysis: An Integrative Review, Empirical Guidance, and Next Steps. Int J Qual Methods 2024;23. https://doi.org/10.1177/16094069241296206.
Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159-74.
Halder, A. Social network analysis of stakeholder governance landscapes in infrastructure mega projects: a case of the Delhi-Mumbai Industrial Corridor project. Innov Infrastruct Solut 2024;9:209. https://doi.org/10.1007/s41062-024-01521-6.
Behzadifar M, Yarahmadi M, Bakhtiari A, Kargar S, Shahabi S, Azari S, Martini M, Behzadifar M. Social network analysis of key stakeholders in Brucellosis prevention in Western Iran. Trop Med Health 2025;53:18. https://doi.org/10.1186/s41182-025-00693-w.
Rahimisadegh R, Noori Hekmat S, Mehrolhassani MH, Jafari Sirizi M. Network analysis of Iranian’s health insurance ecosystem before and after the introduction of Universal Health Insurance law. Glob Health Res Policy 2023;8:16. https://doi.org/10.1186/s41256-023-00302-5.
Waithaka D, Tsofa B, Barasa E. Evaluating healthcare priority setting at the meso level: A thematic review of empirical literature. Wellcome Open Res 2018;3:2. https://doi.org/10.12688/wellcomeopenres.13393.2.
Hawkins L, Kasekamp K, van Ginneken E, Habicht T. Governing health service purchasing agencies: Comparative study of national purchasing agencies in 10 countries in eastern Europe and central Asia. Health Policy Open 2023;5:100111. https://doi.org/10.1016/j.hpopen.2023.100111.
Shahabi S, Ahmadi Teymourlouy A, Shabaninejad H, Kamali M, Lankarani KB. Financing of physical rehabilitation services in Iran: a stakeholder and social network analysis. BMC Health Serv Res 2020;20:599. https://doi.org/10.1186/s12913-020-05447-4.
Shabankareh K, Hamidi A, Soleymani MR, Sajadi HS, Alavi M. Faculty members as academic knowledge brokers in Iran’s health sector: a social network analysis study. Health Res Policy Syst 2024;22:53. https://doi.org/10.1186/s12961-024-01141-7
Alexander JA, Wells R. How do resource dependencies affect treatment practices? The case of outpatient substance abuse treatment programs. Med Care Res Rev 2008;65:729-47. https://doi.org/10.1177/1077558708320407.
Lotfi F, Bayati M, Yusefi AR, Ghaderi S, Barati O. Inequality in Distribution of Health Care Resources in Iran: Human Resources, Health Centers and Hospital Beds. Shiraz E-Med J 2018;19:e63700. https://doi.org/10.5812/semj.63700.
Illenberger J, Flötteröd G. Estimating properties from snowball sampled networks. Social Networks. 2012;34:701-11.