Document Type : Original Article
Authors
1 Khomein university of Medical Sciences, Khomein, Iran
2 Iran university of Medical Sciences, Tehran, Iran
3 National Agency for Strategic Research in Medical Sciences Education; Tehran, Iran
Abstract
Introduction: Sustainable financing of medical education is critical to health workforce development and health system performance. While existing research has largely examined
financing mechanisms and expenditure patterns, less attention has been paid to the policy processes through which financing issues reach the governmental agenda. This study aimed to analyze the agenda-setting process for sustainable medical education financing using Kingdon’s Multiple Streams Framework and Walt and Gilson’s Policy Triangle.
Methods: We conducted a mixed-methods policy analysis, including a scoping review, 15 semi-structured interviews with key stakeholders, and a four-round Delphi process with the same
expert panel. Data were analyzed using framework analysis and interpreted through the two theoretical frameworks.
Results: Economic pressures -including high inflation, international sanctions, declining public investment, and the very low share of education in GDP and health expenditure- dominated the problem stream (mean importance score=4.89/5, expert agreement=97.8%). Demographic shifts, technological demands, and social equity expectations further intensified these pressures. The political stream was characterized by tensions between commitments to free education and limited fiscal capacity, shaped by ideological orientations and external constraints. Although multiple financing alternatives circulated within policy networks, the policy stream remained fragmented, with limited institutionalization of diverse models. Convergence of the three
streams indicated the emergence of a policy window, contingent upon effective policy entrepreneurship.
Conclusion: Effective agenda-setting requires alignment of economic realities, political commitments, and viable policy options. The findings offer transferable insights for other low- and
middle-income countries facing similar structural constraints.
Highlights
Keywords
- Huang F. Higher education financing in Japan: trends and challenges. Int J Educ Dev. 2017;55:1–10.
- Yang L, McCall B. World education finance policies and higher education access: a statistical analysis of World Development Indicators for 86 countries. Int J Educ Dev. 2014;35:25–36.
- He K, Whang E, Kristo G. Graduate medical education funding mechanisms, challenges, and solutions: a narrative review. Am J Surg. 2021;221(1):65–71.
- Schuster BL. Funding of graduate medical education in a market-based healthcare system. Am J Med Sci. 2017;353(2):119–25.
- Kim B, Park N. Lessons learned from financing universal higher education in Korea. Int J Educ Dev. 2018;58:116–27.
- Teichler U. Recent changes of financing higher education in Germany and their intended and unintended consequences. Int J Educ Dev. 2016;46:1–10.
- Marginson S. Global trends in higher education finance. Int J Educ Dev. 2017;55:1–8.
- Poz MRD, Couto F, Franco A. Financing challenges in medical education: transition from elite to mass systems. Educ Health (Abingdon). 2016;29(1):1–8.
- Lung M, Moldovan I, Nistor L, Lung A. Financing higher education in Europe: issues and challenges. Procedia Soc Behav Sci. 2012;51:938–42.
- Goksu AG, Goksu GG. A comparative analysis of higher education financing in different countries. Procedia Econ Finance. 2015;26:1152–8.
- Walt G, Gilson L. Reforming the health sector in developing countries: the central role of policy analysis. Health Policy Plan. 1994;9(4):353–70.
- Chapman B, Doan P. Introduction to higher education financing: student loans. Econ Educ Rev. 2019;70:1–10.
- Jacob WJ, Neubauer D, Ye L. Global trends in higher education financing. Int J Educ Dev. 2018;58:1–4.
- Aizenberg DJ, Logio LS. The graduate medical education (GME) gold rush: GME slots and funding as a financial asset. Acad Med. 2020;95(4):503–5.
- Richards JR, Scheckel C, Newman JR. PROSPER or not? Potential medical education financing reforms and impacts. J Am Osteopath Assoc. 2019;119(2):72–4.
- Gottlieb M, Lee S, Burkhardt J, Carlson JN, King AM, Wong AH, et al. Show me the money: successfully obtaining grant funding in medical education. West J Emerg Med. 2019;20(1):71–7.
- Otero HJ, Ondategui-Parra S, Erturk SM, Ros PR. Financing radiology graduate medical education: today's challenges. J Am Coll Radiol. 2006;3(3):207–12.
- Gury Z. Innovative higher education learning outcomes and financing trends in Israel. Int J Educ Dev. 2018;58:128–36.
- Bentz ML, Ahmad J, Rohrich RJ. Fundraising and philanthropy in plastic surgery: an essential tool for academic excellence. Plast Reconstr Surg. 2011;127(5):2108–12.
- Namazi M, Zare S. Calculation of the Cost of Student Education: A Case Study of Shiraz Medical School. J Adv Med Educ Prof. 2021;9(2):109-22.
- Karimi E, Sohrabi Z, Aalaa M. Change Management in Medical Contexts, especially in Medical Education: A Systematized Review. J Adv Med Educ Prof. 2022;10(4):219-27.
- Alizadeh M, Jafar Sameri M. Intelligent Assessment Systems in Medical Education: A Systematic Review. J Adv Med Educ Prof. 2025;13(3):173-90.
- Hwang R, Paley M, Bull D, Omrani O, Vergara-Jalandoni D, Egbury G. A Systematic Review and Meta-Analysis on the Impact of Peer-Made MCQ Question Bank Usage on Summative Assessments in Medical Education. J Adv Med Educ Prof. 2025;13(4):259-69.
- Toofaninejad E, Rezapour SM, Kalantarion M. Utilizing Digital Twins for the Transformation of Medical Education. J Adv Med Educ Prof. 2024;12(2):132-3.
- Varpahovskis E. Transnational higher education—the case of Kazakhstan. In: Varpahovskis E. Transnational higher education in the Asia region. SpringerBriefs in political science. Cham: Springer; 2023. pp. 87–112.
- Burns KH, Borowitz MJ, Carroll KC, Gocke CD, Hooper JE, Amukele T, et al. The evolution of earned, transparent, and quantifiable faculty salary compensation: the Johns Hopkins pathology experience. Acad Pathol. 2018;5:2374289518777463.
- Richards JR, Scheckel C, Newman JR. PROSPER or Not? Potential Medical Education Financing Reforms and Impacts. J Am Osteopath Assoc. 2019;119(2):72-4.
- Grewal K, Sweeney MJ. An innovative approach to educating medical students about personal finance. Cureus. 2021;13(6):e15579.
- Li W, Liu Q. Chinese higher education finance: changes over time and perspectives to the future. Procedia Soc Behav Sci. 2013;77:388–411.
)