Unlocking Transparency, Building Trust: A Policy Brief for a Developing Health System

Transparency in health systems is defined as providing open access to information, including patients' health records, treatment options, provider details, service costs, and outcomes (1, 2). It also involves information sharing among stakeholders to improve learning, establish standards, and shape organizational culture. Transparency ensures that stakeholders can access sufficient relevant information accurately and timely in an appropriate and understandable format.

Transparency is the cornerstone of good governance. However, in many developing countries such as Iran, it is underdeveloped (3). Numerous studies have examined the outcomes of transparency in health systems, outlining a range of benefits including increased accountability and responsibility, enhanced competition (4), improved treatment outcomes (1, 5), strengthened trust, better patient experiences (2), lower service costs, and improved health market efficiency (4, 6). Additionally, transparency empowers patients to play an active role in their choices and contributes to health system reform (7). Nevertheless, transparency can lead to unintended consequences, such as decision-making errors, provider reluctance to accept high-risk patients, and decreased patient trust (8). In some cases, transparency is symbolic without achieving its goals.

Therefore, principled and effective policies tailored to specific contexts are needed to promote transparency, reduce its unintended consequences, and maximize its benefits. This policy brief, based on a qualitative study conducted from 2022 to 2024 as part of a doctoral thesis, outlines the general principles for enhancing transparency and provides recommendations for Iran’s health system, which can serve as a model for other developing countries. Details on the methods and setting are provided in Appendix 1 in Supplementary File.

Few studies have assessed the transparency of Iran's health system, and existing evaluations are unfavorable. Nargesian and Jamali found that the Ministry of Health (MoH) ranked among the least transparent of all government ministries, concluding that "the MoH's position warrants further discussion, given its crucial role in treatment and the fate of the people" (9). The Iran Information Technology Executive Council ranked the MoH 88th out of 139 executive bodies, assigning it a transparency score of just 6% based on 14 weighted indicators, such as expenditures, contracts, tenders, assets, regulations, permits, and appointments (10). The Global Open Data Index ranked Iran 67th out of 94 countries, with 21% of data published openly. Even in instances of relative transparency, expert interviews highlight a lack of systematic and comprehensive transparency, often revealing it to be symbolic and deceptive (11).

While this situation reflects the country's political system, the health system is not as transparent as expected. This situation has deep-rooted causes that are difficult to address, stemming from fundamental issues related to the level of democracy, monopoly, and concentration of power, as well as cultural factors (12). While some causes may be unique to Iran, many are also present in other countries, such as the "lack of sufficient and standardized data" and "political controversies," observed in the UK, US, Australia, and Uruguay (12-15). The lack of transparency leads to conflicts of interest, corruption, inefficiency, lack of accountability, and decreased social capital, potentially endangering lives and reducing public access to services (16).

While some argue that non-transparency allows managers more freedom and risk-taking, the drawbacks, such as weakening the rule of law and arbitrary management, outweigh these benefits. Furthermore, the lack of transparency has compromised other health reforms, such as the family physician and health transformation plan. Therefore, reforming the governance of Iran's health system, including enhancing transparency, is essential for the success of other policies.

Due to the lack of transparency in Iran's health system and to improve health policies, equity, and access to health services, the following policy recommendations are provided as a general guide for health activists, scholars, and policymakers to enhance transparency:

(1) Establish robust infrastructure: Develop strong political, economic, technological, and cultural foundations for transparency, including political commitment, legal reforms, resource allocation, staff training, and public awareness. Employees should view transparency as crucial for enhancing their work. However, organizational culture will only transform when transparency is fully integrated into the system and its ongoing processes.

(2) Engage transparency advocates: Support and collaborate with transparency activists to promote transparency initiatives.

(3) Overcome socio-political barriers: Identify and address barriers and risks that hinder transparency efforts.

(4) Develop a sustainable strategy: Create a long-term plan focusing on proven positive outcomes, such as quality and safety of care.

(5) Stakeholder and community engagement: Involve stakeholders and the community in transparency planning and implementation to maximize the value of open data.

(6) Encourage ecosystem collaboration: Support the development of an ecosystem where data producers, government organizations, data users, and related tools and services work together.

(7) Strengthen organizational capacity: Enhance technological and organizational capacities, including digital infrastructure and staff training.

(8) Localize transparency initiatives: Adapt transparency efforts to align with the health system's infrastructure and cultural norms.

(9) Develop a phased approach: Implement transparency gradually to manage the transition effectively. Start with small steps and don't wait for perfect conditions, as an ideal situation is hard to achieve even in developed countries.

(10) Publish quality information: Release valuable and high-quality data while maintaining confidentiality, and utilize tools such as centralized data portals, AI, and social networks to facilitate access.

(11) Create feedback mechanisms: Establish public feedback systems to address deficiencies and support further transparency.

(12) Encourage public participation: Empower citizens to participate in transparent decision-making and policymaking processes.

(13) Support innovation and openness: Promote innovation in government and leverage civic technology.

(14) Monitor and evaluate: Continuously monitor and evaluate transparency efforts to identify improvements and ensure desired outcomes.

Transparency is essential for advancing healthcare and will become increasingly important as the industry evolves. The recommendations outlined above provide a strategic framework for achieving this goal by fostering robust infrastructure, engaging stakeholders, overcoming barriers, and implementing sustainable transparency initiatives. A gradual, well-planned approach — supported by technological advancements, public participation, and continuous monitoring — will create a culture of openness that strengthens accountability and trust. By prioritizing transparency, Iran's health system can evolve toward greater efficiency, inclusivity, and responsiveness, ultimately benefiting both policymakers and the public.