Challenges of parliamentary engagement in health policymaking in Iran: a qualitative study using Gaventa’s power cube framework

Parliaments play an important role in health governance through legislation, budgeting and oversight. However, their practical influence on health policy decisions remains poorly understood in systems where executive institutions and expert actors dominate policy processes. In Iran, health governance is characterized by centralized authority, fragmented institutional arrangements and strong professional hierarchies. This study explored the challenges of parliamentary engagement in health policymaking using Gaventa’s power cube framework. A qualitative descriptive study was conducted using semi-structured interviews with 32 participants, including senior health officials, health policy advisors with experience in parliamentary engagement, representatives from insurance and regulatory bodies, professional association members and health policy academics and researchers who had direct or indirect involvement in health legislative processes. Participants were selected through purposive maximum variation sampling. Data were analysed using reflexive thematic analysis, with initial inductive coding followed by abductive theoretical interpretation through the dimensions of Gaventa’s power cube framework, examining how spaces, levels and forms of power interact to shape parliamentary engagement. Three interrelated themes emerged. First, parliamentary engagement occurred largely within invited policy spaces, while key agenda-setting processes remained concentrated in closed executive and expert arenas. These closed spaces were reinforced by hidden power mechanisms, including selective information dissemination and strategic control over policy framing. Second, fragmented authority across multiple governance levels diluted accountability and constrained effective legislative oversight. Transnational dynamics, including international sanctions, global health organizations and external resource constraints, introduced an additional layer of complexity that further limited parliamentary influence. Third, visible legislative powers were shaped by hidden and invisible forms of power, including control over information, agenda-setting processes, professional authority and dominant expert discourses. Crucially, these three forms of power did not operate in isolation but interacted to create a self-reinforcing cycle: invisible power (professional legitimacy) legitimized closed spaces, while hidden power (agenda control) operated within fragmented governance structures to dilute accountability. Together, these dynamics limited Parliament’s capacity to influence policy formulation and positioned legislative engagement as predominantly reactive rather than proactive. Parliamentary influence in Iran’s health policy system is shaped not only by formal legislative authority, but also by the interaction of policy spaces, governance levels and multiple forms of power. Applying Gaventa’s power cube framework reveals how executive dominance, institutional fragmentation, transnational influences and epistemic authority collectively constrain legislative participation in health policymaking. By demonstrating how closed spaces, fragmented levels and interacting forms of power mutually reinforce one another, this study contributes to a more nuanced understanding of parliamentary engagement in complex health governance systems and offers insights for strengthening legislative involvement in evidence-informed policy processes.