A policy context and process analysis to implement the Paris Agreement on climate change in the health system of Iran.

Background: Ensuring public health is crucial in any policy debate on climate change. Paris Agreement on Climate Change is a global contract through which countries have committed themselves to a public health treaty. This study was conducted to identify the challenges that lie ahead for policymakers and provide an evidence-informed framework for policymaking to increase the resilience of Iran's health system to health consequences of climate change.

Methods: A qualitative study using semi-structured interviews was conducted with 25 experts. Purposeful and snowball sampling techniques were used for data gathering. Thematic content analysis was conducted with a deductive-inductive approach. Leichter's model, the stage's heuristic framework, and Kingdon's models were used for analyzing the context and process analysis respectively. MAXQDA 20 software was used.

Results: A total of four main themes and twelve sub-themes were identified concerning various contextual factors, including political, economic, international, and cultural/social challenges. The primary obstacles to implementing adaptation measures were found to be political considerations, economic sanctions, and the low-risk perception held by both the public and policymakers. Additionally, fifteen themes and forty-eight sub-themes related to the process were identified across several areas: agenda setting, which includes the problem stream, policy stream, and politics stream; policy formulation, encompassing governmental and managerial aspects, research, evidence-informed policymaking, and the role of Non-Governmental Organizations; policy implementation, which covers early warning systems, education, inter-sectoral coordination, architecture and engineering, and integrated databases; and policy evaluation, focusing on inadequate evaluation methods.

Conclusions: The study identifies key challenges in implementing the Paris Agreement within Iran's health system, categorized into four main themes: political, economic, international, and cultural/social. Political issues stem from the politicization of climate change and national security concerns. Economically, reliance on oil and sanctions hinder progress, while high technology costs strain resources. Internationally, a lack of binding commitments and technological sanctions impede efforts. Culturally, low public awareness and inadequate inter-organizational collaboration limit engagement. The study emphasizes the need for cohesive policies, enhanced public education, and improved coordination among sectors to effectively address climate change impacts on health.