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Health Sector Reform Following COVID-19 Outbreak: Using Kingdon’s Multiple Streams

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Shiraz E-Med J. In Press(In Press):e106674.
Published online 2020 July 4.
doi: 10.5812/semj.106674.
Health Sector Reform Following COVID-19 Outbreak: Using Kingdon’s
Multiple Streams
Saeed Shahabi 1and Kamran Bagheri Lankarani 1, *
1Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
*Corresponding author: Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran. Email:
Received 2020 June 21; Accepted 2020 June 23.
Keywords: Health Reform, COVID-19, Kingdon’s Multiple Streams, Iran
Since 20 February,when the first cases of COVID-19 were
detected in Iran, the Iranian health sector has borne heavy
burdens, with 182,545 positive cases and 8,659 deaths as of
12 June 2020 (1). Due to explosive spreading of COVID-19,
Iran experienced one of the highest burdens of the COVID-
19 pandemic in the early days (2,3), in such a way that the
intensive care units (ICUs) were almost full. In response,
the Ministry of Health designated a number of hospitals
for coronavirus patients and suspected patients in differ-
ent cities, meanwhile trying to encourage mild and mod-
erate patients to home quarantine themselves (4). Fur-
thermore, extensive training programs developed to in-
form the public about effective ways to prevent disease and
transmission of the virus (5).
Despite these measures, the incidence rate of COVID-19
in Iran is still significant, which has created various chal-
lenges for the whole country as well as the health sector,
like other nations. Based on the available evidence, the
response of countries to this pandemic has been strongly
influenced not only by the structure and organization of
the health sector but also by the position of public health
and primary health care in their health system (6,7). For
instance, although Veneto and Lombardia are two quite
neighboring regions in northern Italy, their performance
was meaningfully different in responding to COVID-19 (8,
9). In fact, Veneto’s better performance comes from poli-
cies such as: early active screening, proactive tracing of po-
tential positive cases, and home diagnosis and care. Con-
ducting effective and community-based health reforms is a
crucial step in proper reaction to outbreaks, such as COVID-
19 (8). Recognizing the current window of opportunity to
fundamentally reform the health system in the light of an-
alyzing the successes and challenges in the management
of the current pandemic of COVID-19 through wise consid-
eration of Kingdon’s multiple streams framework (Figure
1) could be of utmost importance for an adaptive and effec-
tive reform in a health system (10).
Although a series of measures have been taken to curb
and control the spread of COVID-19, a number of prob-
lems have slowed down the fight against the disease glob-
ally and in Iran including (1) lack of proper tracking and
tracing of potential patients; (2) Late stoppage of interna-
tional and domestic travels; (3) weakness in diagnosing
and defining the disease; (4) continuing gatherings; (5)
insufficient public transportation and overcrowding; (6)
crowded medical centers with many interactions; (7) ex-
istence of crowded residential complexes; (8) inappropri-
ate reductionism of the current pandemic; (9) weakness in
collaboration and teamwork; (10) delay in applying predic-
tive models to facilitate forecasting; and (11) lack of com-
prehensive policies to attract public support (4).
However, combating against this pandemic has been
marked by significant successes , which in the case of
Iran include: (1) partnership of elites and religious lead-
ers with the health system and their advocacy of health
sector decisions; (2) using the Primary Health Care (PHC)
network to track and identify suspicious cases as well as
facilitating the home-based quarantine of positive cases;
(3) rapid expansion and strengthening of laboratory net-
works throughout the country; (4) use of information tech-
nology infrastructure for registration and tracking; (5) suc-
cess in reducing travel and interactions during holidays;
(6) success in involving non-governmental organizations
and science-based companies in supplying needed devices
and personal protective equipment; (7) success in imple-
menting preventive measures and social distancing poli-
cies in some difficult environments such as prisons and
temporary discharge of low risk incarcerated persons; (8)
using virtual education and keeping pupils and students
away from public environments; and (9) increasing the
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Shahabi S and Bagheri Lankarani K
Kingdon’s multiple streams
(e.g. severity, metrics, anecdotes)
Focused events
(e.g. epidemic, natural crisis)
Feedbacks & reactions
Policy entrepreneurs
Technical feasibility
Value acceptability
Political feasibility
National mood
Public behavior
Administration changes
Pressure groups
Interest groups campaigns
Window of opportunity
Agenda setting
Figure 1. Diagrammatical representation of the Kingdon’s multiple streams framework
public awareness about the disease and also the effective
ways to prevent transmission (5,11,12).
Despite all challenges posed to the health sector, the
COVID-19 pandemic has prepared a favorable opportunity
for comprehensive and evidence-based reforms in health
systems worldwide and in Iran. In accordance with the
Kingdon’s multiple streams, when three streams or events
(problem, policy, and politics) collide, the window of op-
portunity will be open for policy entrepreneurs to develop
and propagate their issues in agenda-setting processes (13).
The current COVID-19 pandemic is currently one of the
main concerns of the public, politicians, and experts. Thus,
COVID-19 has become very important socially, and there is
public expectation from the government and the govern-
ing structures to take action. This is a window of oppor-
tunity to take advantage of the focus on health by all, to
launch a profound reform in the health sector.
Although the importance of PHC and a referral system
are well-recognized axes of such a reform (14), this process
will not be easy. There is a range of issues which may af-
fect the reform planning and implementation especially in
Iran including idealism without effective change program,
2 Shiraz E-Med J. In Press(In Press):e106674.
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Shahabi S and Bagheri Lankarani K
heterogeneity in the different parts of the country with re-
gards to culture and economic and social aspects, conflict
of interests among the decision-makers, failure of the ur-
ban Family Physician Plan (FPP) in the current form in Iran,
immigration to big cities and increasing marginalization
and indwellers of the suburbs and ignoring cost-effective
Furthermore, given recent events such as the start-
ing of a new parliament, greater public confidence in the
health care system, solidarity among the public and au-
thorities following the COVID-19 outbreak, as well as eco-
nomic issues following international sanctions and declin-
ing oil revenues, the experience of change and conduct-
ing health reform programs in Iran especially in establish-
ing the PHC during the imposed war against Iran some 34
years ago (15), the existence of information technology in-
frastructure, Iranian Health Insurance Organization (IHIO)
and other insurance companies, can be potential factors
that provide a good platform for developing and imple-
menting effective reforms.
In general, due to the intersection of the three streams
(problem, politics, and policy) and preparing opportuni-
ties for health policy entrepreneurs for reform in the Ira-
nian health system, these suggestions could be made (1)
moving towards a holistic medical education; (2) promot-
ing the strategic values of integrating medical education
into the health care system; (3) developing a system for
continuous monitoring of diseases and potential hazards;
(4) determining the health needs of different population
groups; (5) rationing and prioritizing the interventions
based on available resources, disease burden, fairness, ac-
ceptability, etc.; (6) integrating the adopted policies; (7) de-
veloping a clear executive mechanism for policies and also
determining transparent outcomes for them; (8) consider-
ing the process model of providing health services as a ba-
sis for designing the health care structure; (9) strengthen-
ing the referral system and FPP; (10) prioritizing the public
In addition to the above recommendations, given the
importance of the PHC network in the fight against dis-
eases, especially epidemics and pandemics, improving this
network should be the main priority of the Iranian health
system as well as other nations in the coming years. A
number of policy solutions could improve this network
including (1) redesigning the PHC network integrating
health, treatment and medical education; (2) moving to-
wards financial independence and accountability of the
PHC network; (3) increasing public participation and bet-
ter communication with local councils and authorities;
(4) empowering health care providers and health workers
(Behvarz); (5) promoting team working; (6) establishing
the FPP with the support of general practitioners; (7) us-
ing appropriate payment mechanisms such as capitation
and pay-for-performance; (8) designing the health benefits
package with a focus on preventive and basic health ser-
vices; (9) diminishing the out-of-pocket payments using a
comprehensive referral system, and (10) continuous mon-
itoring of the PHC network performance and short-term
and long-term consequences of measures.
To manage these activities, the headquarters of the
ministry of health needs reform in structure and func-
tion. In this regard, these issues should be considered: (1)
strengthening the planning dimensions and function and
strategic supervision process; (2) moving towards agility
and innovation; (3) using specialized workforces; (4) re-
ducing executive duties and promoting governance du-
ties; (5) improving communication with the public and
developing advocacy plans; (6) effective management of
inter-sectoral collaborations; (7) using the principles of op-
erational budgeting, and (8) setting clear goals in order to
hold the authorities accountable.
In conclusion, the current window of opportunity for
health sector reform is a unique occasion that could lead to
a healthier world for all and more rapid access to universal
health coverage. The current solidarity by all toward the
health system should be valued and approached appropri-
Authors’ Contribution: Both authors were involved in
study design and writing the manuscript.
Conflict of Interests: Authors who have no relevant finan-
cial interests are asked to provide a statement indicating
that they have no financial interests related to the material
in the manuscript.
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