Do subsidies reach the sick? Implementation challenges and equity implications of pharmaceutical subsidy reform in Iran: a qualitative study

BACKGROUND: Pharmaceutical subsidy reforms are commonly implemented to improve access to essential medicines, strengthen financial protection, and enhance the sustainability of health systems. In Iran, the Darooyar policy was introduced to shift pharmaceutical subsidies from subsidized foreign exchange allocation toward consumer-oriented insurance coverage. Despite its policy importance, limited evidence exists regarding the implementation challenges of this reform from the perspective of health system stakeholders. METHODS: This qualitative study was conducted using an inductive thematic analysis approach. Data were collected through 27 semi-structured interviews with policymakers, pharmaceutical sector managers, insurance experts, and stakeholders involved in the regulation and implementation of the policy. Participants were selected through purposive and snowball sampling to ensure diversity in organizational affiliation and implementation experience. Data were analyzed following Braun and Clarke's six-step thematic analysis framework. RESULTS: The findings revealed that implementation of the pharmaceutical subsidy reform in Iran was associated with complex challenges related to financing, governance, inter-organizational coordination, and implementation infrastructure. Major challenges included unstable financial resources, delayed reimbursements, liquidity shortages across the pharmaceutical supply chain, institutional fragmentation, weak coordination among responsible organizations, and insufficient monitoring and information systems. Participants also highlighted tensions between maintaining financial protection for patients and ensuring the rational use of medicines. Although the policy was perceived to have reduced reverse drug smuggling and improved insurance coverage, weaknesses in governance arrangements and implementation capacity constrained its effectiveness. CONCLUSION: The study demonstrates that pharmaceutical subsidy reform is not solely an economic intervention but a complex governance process whose success depends on financial sustainability, institutional transparency, implementation capacity, and coordination among health system actors. Strengthening accountability mechanisms, developing integrated monitoring systems, and improving inter-organizational coordination may enhance the effectiveness and sustainability of pharmaceutical reforms in resource-constrained health systems.