Interpreting Pharmaceutical Policy Change in Iran: A Qualitative Multiple Streams Analysis of the Darooyar Reform Under Sanctions

Background Iran’s pharmaceutical sector has faced a severe, multifaceted crisis, driven by structural inefficiencies and intensified by international sanctions. In response, the government launched the Darooyar reform in 2022, replacing the long-standing preferential currency allocation with an insurance-based subsidy model. Understanding how this politically sensitive reform emerged under conditions of economic distress and institutional fragility requires an analysis beyond linear policymaking models. Methodology A qualitative single-case study design was adopted, guided by Kingdon’s Multiple Streams Framework (MSF). Data were collected through 16 semi-structured, in-depth interviews with key stakeholders—including policymakers, insurance officials, pharmacists, and academics—conducted between May and November 2024. Thematic analysis, supported by MAXQDA software, was used to map the convergence of the problem, policy, and politics streams, as well as the role of policy entrepreneurs. Results Findings reveal that the reform was driven by the alignment of three streams: (1) a critical problem stream characterized by fiscal instability, market distortions, and mounting patient pressure; (2) a viable policy stream, with the Darooyar model positioned as a pragmatic middle-ground solution; and (3) a receptive political stream shaped by the 13th government’s economic reform agenda, parliamentary dynamics, and coercive pressure from sanctions. Policy entrepreneurs, particularly within the Food and Drug Administration and Ministry of Health, played a pivotal role in coupling these streams and strategically framing the reform to ensure its adoption. Conclusion The study advances the theoretical application of MSF by demonstrating how external shocks and institutional constraints shape stream dynamics and policy convergence in a middle-income, sanction-affected setting. Empirically, it provides insights into the complexity of pharmaceutical financing reforms under economic and political stress, offering lessons for similar contexts. However, post-implementation challenges—such as rising out-of-pocket payments and delayed insurance reimbursements—highlight the need for adaptive governance and continuous policy learning to sustain reform outcomes.