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Health policy analysis in Eastern Mediterranean region using a health policy triangle framework: Historical and ethical insights from a systematic review

Summary Background Health policy can be defined as an agreement and consensus on a health-related program and set of actions taken to achieve the goals expected by programs in the area of policy. Policy analysis involves a wide range of methods, techniques, and tools in a way to reach awareness of the impacts of the developed and implemented policies. Whereas policy analysis in developed countries has a long history, in developing countries, it is instead in its first developing stages. Our paper aimed to collect systematically the studies using health policy triangle framework in doing analysis in one of the health policy issues in the Eastern Mediterranean region organization. Methods To conduct our literature search, ISI/Web of Science, PubMed/MEDLINE, Embase, The Cochrane Library, Global Health Database, Scopus, as well as Google Scholar from 2003 up to June 2020 were systematically mined. To evaluate the methodological quality of the included studies, the Critical Appraisal Skills Program checklist was used. Results We selected 30 studies, conducted between 2011 and 2020. According to the findings of these studies, in the Eastern Mediterranean region, organization region, and the role of evidence-based research in policy-making has been repeatedly emphasized, but its use in health program decision-making has been limited, and health research systems in Eastern Mediterranean region organization are still under scrutiny. There is still a gap between evidence-based research in health systems and its use in policy-making. Discussion Based on the present systematic review, studies based on policy analysis should focus on all the elements of health policies and provide evidence to inform decisions that can strengthen health systems, improve health and improve existing inequalities.


Results
This study adhered to the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) guidelines. 863 articles were found in the initial search. 172 articles were duplicated and, as such, were removed. The titles of 691 articles were reviewed. 572 were removed, being unrelated studies. 30 studies were finally selected based on the study criteria. Figure 2 shows the process of searching and selecting studies . Selected studies were conducted between 2011 and 2020. Studies were conducted in Iran (16), Pakistan (4 studies), Saudi Arabia (2 studies), Lebanon (2 studies), Sudan (2 studies), Tunisia (2 studies), Egypt (1 study), Afghanistan (1 study), Syria (1 study) and Palestine (1 study). One study was conducted in four countries (Tunisia, Syria, Palestine, and Turkey). Figure 3 shows the studies according to the EMRO countries in which they have been performed.
The methodological quality of the selected studies Table I and Figure 4 show the quality of studies broken down according to the previously mentioned classification (good, moderate, and poor quality). Based on the scores obtained, 20 had good quality, 9 had moderate quality, and 1 had poor quality. The main characteristics and findings of the selected studies are shown in Table II.

Discussion
Policy analysis is a valuable process for understanding policy processes, identifying the determinants of the failures and successes of past policies, and planning for future ones [13], and is also complex due to the diverse nature of health issues [13,47]. The present study assessed published studies related to health issues in the Eastern Mediterranean region using a Health policy triangle framework. The findings of the present study were selected from thirty extracted articles. With the exception of one study [34], all studies were retrospective. It seems that in order to evaluate the programs of the health system, it seems that in order to evaluate health system programs, it is better to pay attention to studies with prospective design and put it on the agenda, because evidence arising from these researches in improving the health systems and providing services by policymakers and researchers would be of higher quality and strength. Policy analysis can show the agility and dynamism of countries' health systems [48,49]. Findings of studies based on four elements of study (context -why do you need this policy -, content -what is the policy mainly about-, process -how this policy is designed and implemented -and actors -who participate and influence policy formulation and implementation) were analyzed and reported.

Context
The policy analysis process should be such as to reflect a thorough understanding of the context, decision-making, planning and implementation of policies. Because health issues go beyond health care and are influenced by psychosocial, economic and environmental factors [13,47], health policy-making is an inherently political process, which is influenced by the social and political context, and therefore understanding and analyzing political systems can help better assess the context and why a given policy is chosen [50]. Demographic, epidemiological, educational, technological, cultural, as well as social developmental, economic and financial issues, the specific type of political regime are some of the issues that should be seen in context [51]. In the included studies, political and administrative factors, as well as economic and financial one, and social and cultural variables, personal and political interests, promotion of international standards of sectarianism, urgency and values of policymakers and media policies are the most important underlying parameters determining the success of a given health policy. Impacts on specific policies were reported. In most of the selected studies, the contextual factors of the country of the study did not have a direct impact on the choice of policy for analysis. It seems that the priority criteria for policy analysis in EMRO countries should be more transparent and the use of evidence should be increased. This could contribute to a more efficient and effective use of financial resources for policy analysis research [52]. Topics analyzed by researchers in selected studies included high prevalence or mortality rates, WHO reports, the Sustainable Development Goals (SDGs), Universal Health Coverage (UHC) achievement. Researcher evaluated also whether political decisions to solve a problem were taken based on evidence. Despite the fact that the type of political system, financing and Gross Domestic Product (GDP) per capita allocated to health programs are important elements in health policy making and can influence health policies related processes, none of the studies included in the present systematic review focused specifically on these factors and their impact on the policy in question. The health policy triangle framework states that national, international, political, economic and social factors can influence health policies. However, based on the Leicher's classification of these factors, some of which depend on circumstances, structural, cultural, and international factors, most of the selected studies did not pay full attention to these issues and paid less attention to their impact. These issues can be effective in creating a tendency to analyze or not analyze a policy in the health sector. One of the important points was the attention of the researchers of the selected studies to the selection of topics related to diseases and issues such as health justice, health finance, governance, use of evidence whereas other issues were less analyzed. Perhaps one of the reasons for choosing diseases for policy analysis is easier access, greater participation of people in these studies, which encourages EMRO researchers to analyze them. Of course, the nature of some issues in the health sector may make researchers less interested in analyzing them. They may be conservative and not accept the problems they need to gather information about them. On the other hand, due to political issues such as wars and sanctions in the EMRO region and its great impact on the health sector, the influence of these issues has received less attention. Ethnic and national prejudices have not been accounted for in the analysis of health sector policies in the countries of this region. Religious tendencies in this area have not been considered in selected studies. The existence of wars in Afghanistan, Syria and Yemen and the sanctions on Iran can affect the process of policy analysis of health-related issues. Lack of full vaccination coverage, failure to achieve the Millennium Development Goals (MDGs) goals, inadequate access to health services, reduced health budgets, issues related to children, women and the elderly, immigrants and refugees problems, as well as economic-financial problems and declining incomes, can dramatically impact health funding and resources allocation, which in its turn further complicates these problems.
To analyze a policy in the health sector, one should not be utilitarian and conservative. You have to see the underlying issues. These affect the success or failure of that policy. Policy analysis is a dynamic and political process. The diversity of EMRO countries' political systems is crucial in implementing or not implementing health sector policies. The attention and priorities of policymakers in these countries can influence the choice of a given issue for policy analysis. Unfortunately, this issue has received less attention. Researchers seem to have sought to analyze issues that are more influenced by international factors.  health initiatives and related issues or programs that were felt needed and pursued by other health-related organizations. It seems that in EMRO countries, the main focus for the implementation and start of health programs is only the Ministry of Health, and due to over-reliance on this ministry, the process of programs is unipolar and still or other organizations are not sensitive in this regard or if there were no documents. While health should be current and considered in all policies in countries. At the heart of "Health in All Policies" is the study of health determinants, which are largely controlled by policies of sectors other than those involved in health, because in the "Health in All Policies" process, addressing the social factors of health and disease can be a powerful tool for reducing health inequalities [55]. Health is highly influenced by lifestyle and environment and many health issues are simultaneously deeply affected by factors outside the traditional realm of health and healthcare. Factors such as literacy, poverty, employment and racism contribute to differences in life expectancy as well as health-related quality of life. Concerns about how to address these factors have led to a focus on "health in policies", in which policies in the social sectors such as transport, housing, employment and agriculture can ideally focus on health and access to health contribute to equity in health [56]. Once the problems are identified, the content analysis will focus on the suggestions and goals themselves. Sources (material and political) should be mentioned in the discussion of the content of a policy. Material resources, such as equipment and money and technical and organizational resources, this type of resources means the knowledge and organizational and managerial abilities to implement the proposals. Moreover, political resources are essentially the power to implement a policy. None of the studies addressed this issue.

Process
In the analysis of this section, what should be considered is to describe the process of health policies, ie policy formulation and implementation of policies and issues related to them. If Walt considers the three main aspects of the policy process to be the following: The issue of power in terms of who makes decisions and who influences them. The concept and types of policies in terms of what politics is and how it is policy-making, and the logic and rules of politics in terms of its formation as a logical process.
Tab. I. Quality appraisal of the studies included in the present systematic review.
The first author (References)  Q1  Q2  Q3  Q4  Q5  Q6  Q7  Q8  Q9  Q10  The score of  the quality  Categories   Beesley (14)  1  1  1  1  1  NA  1  1  1  1  9  Good  Zaidi (15)  1  1  1  1  1  1  1  1  1  1  10  Good  Phillimore (16)  1  1  1  1  1  1  1  1  1  1  In Palestine, the health system for policy making and implementation of programs in the field of these two diseases with problems such as lack of cohesion of the health system, reliance of the system on foreign donors, lack of stable information systems and lack of access to patient data and non-sharing of this information. There are differences between different parts of the health system and the lack of retention of employees, especially doctors. In this country, despite spending 64% of expenditure on health on health care, only 7% of it is spent on the prevention of public services. Although these two diseases are one of the main challenges in Syria, there is a lack of coordination and planning in different parts of the health care system. There was no systematic followup of weak patients to refer patients from primary to secondary care. There is no system for recording patient records, especially in rural and rural areas, and there has also been a severe shortage of skilled staff in the health system, especially outside major cities.
In Tunisia, there are four frameworks and structures for NCD management, but there are no coordination, monitoring, and implementation mechanisms, and fragmentation of the system prevents coherent management of the disease. Strategic partnerships have not been strengthened, and policymakers are reluctant to see the disease as part of an economic and social development strategy, and the focus of participation is on health care, not prevention, and so inter-sectoral and conscious participation is weak.
There was coordination and integration in the Turkish health system, and the structure (The new Family Health Center framework) was formed, which was inconsistent. Moreover, the Health Transformation Programme (HTP) reforms play an important role in primary care (for prevention, diagnosis and treatment) . However, the diagnosis and monitoring of non-communicable diseases has been neglected and poor, and there is no proper referral system. was approved quickly over a period of days because it was merely a symbol of the government's efforts to have a new policy that could serve as another sign of that government, but no evidence. The discourse or measurement process of the options available was not anticipated. In the two key periods before and after the transfer of health to the provinces, the policy-making process was formed primarily at the federal and provincial levels, but the implementation process has faced many challenges. Political decisions have taken place in an unorganized and almost aimless manner. Furthermore, there is no process for knowing the evidence. Decisions are usually delayed and few are made arbitrarily, usually by the Office of the Minister of Health. Where political leadership is strong (for example, the senior minister of Punjab province) plays an active role, but this situation is less desirable in other provinces and regions. Programs are either not approved or are implemented incompletely. The current system for data collection and management, including the health management information system and the district health information system, is only running in five of the 30 areas. and face-to-face semistructured face interviews. Hospital accreditation is an external evaluation system aimed at assessing patient quality and safety and encouraging continuous quality improvement.
It is developed by an independent accreditation body and local professional institution to evaluate the hospital in terms of structures, processes and results (outputs/ outcome) using predefined and optimal standards. 2157 accreditation criteria for the accreditation of 36 departments of the hospital Two accreditation criteria were developed for accreditation of 36 hospital wards and it was taught at the university and hospital level.
It was mandatory and monitored by hospital evaluators, and then Nonstandard hospitals were required to address problems and improve performance over a specified period of time In 2012, the hospital's appraisal system was renamed and upgraded to a hospital accreditation system, which used the department's method to develop accreditation standards for Iranian hos-  it is still a major health problem in these countries. The UNICEF Global Health Program for Children is GOBI-FFF, which includes seven programs. The content of policies adopted in Iran includes two main categories in accordance with UNICEF policy: quality-based of life policies (the most important of which include nutrition promotion policies), which are the three main policies of breastfeeding, nutrition of children under 5 years and control of micro-nutritional deficiencies include iron, iodine, vitamin A and vitamin D. In the above documents, the issues of mother and child are important and it is necessary to take care of them Politicians are more focused on mother and child issues than on other groups. After examining the current situation and prioritizing the problems of the provinces of the country based on malnutrition and indicators were created to measure the deficiency of micronutrients, efforts were made to involve other organizations and test policies. Appropriate policies were adopted and implemented as executive guidelines.
Has been notified Feedback has been received from other organizations involved in child affairs, and self-assessment of the activities of the organizations and monitoring of the implementation of the activities has been done.   In some of the articles included in the present systematic review, some explained the program and its purpose, while others described the activities of care centers and decision-making committees such as the National Committee for Hepatitis and Acquired Immunodeficiency Syndrome (AIDS), etc. Some considered the reason for the programs to be due to the urgency of the issue and other than political decisions. Some studies have pointed to the implementation and structural challenges of programs and policies, the latter of which has been highlighted in these studies as one of the factors in the failure of health programs. Other reasons for the programs' failure include internal wars and crises, weak financial and technical capacity, disputes between states, sanctions, and declining funding for national standards produced without infrastructure. It seems that one of the reasons for the failure of the programs was the lack of proper prioritization to solve the problems under study, as mentioned in the articles. Because in order to succeed in promoting health programs, it is very important to pay attention to prioritization and criteria (which must be clearly defined and understood by decision makers and stakeholders in each country) and should not be the sole responsibility of specific institutions or ministries. Therefore, in all policies, stakeholders and supporters should be considered as key factors. As shown in these studies, programs that sought advocacy were more successful because advocacy as a key strategy to achieve the goals of health promotion and Advocacy organizations play a key role in promoting justice in health, given global challenges, research and policy [57]. Also, health should be separated from political issues and levels of health governance, policies and measures should be complementary to each other because participation in health governance, policy-making and development of interventions and its implementation by sectors other than health is important and health is mainly outside. Areas and levels of health are created and attention to the creation and implementation of health in all policies strengthens the potential that other sectors have for health [58]. It should be noted that developing countries underestimate the role of education in their policies, and the budgets allocated for health education in these countries are very small and health policy makers pay very little attention to this issue. Therefore, indigenous educational projects should be designed in accordance with the context of communities, and on the other hand, executive decision-making groups should be multidisciplinary, and their roles should be clearly defined before determining program priorities, and involving groups other than Medical teams are very effective in advancing goals [44,45,52].

Actors
The WHO in its 2000 report defined health systems as "all organizations, institutions, and resources dedicated to the production of health measures," which includes a full range of actors and health care providers, including sectors. Private, non-profit, non-governmental organizations (NGOs) as well as international donor foundations [59]. Therefore, health systems are operating at the central, regional, local, social and home levels, and all of these institutions must be considered at all levels of strengthening health systems. Actors include any institution, character, or social movement that has the ability to influence health events, and a common feature of all social actors is that they have a certain amount of power.
The most important actor mentioned in the present study was the Ministry of Health. Several articles referred to the role of domestic and foreign NGOs. NGOs play an important role in providing health services and health policies, and the importance of these organizations in providing health services in low-and middle-income countries has become increasingly important [60]. In poor countries, they are more effective and efficient than public organizations and act as agents of change in international economic, social and environmental policies. It seems that EMRO countries have not yet been able to use the effective potential of NGOs in advancing health policies, ignoring the need to strengthen government health programs and cooperate with organizations to achieve the goals set in the SDGs and improve the quality and efficiency of health care. Non-governmental support is therefore essential [61]. The involvement of NGOs with the public sector should play a key role in addressing justice issues and improving the quality of services provided, along with addressing system access and accountability issues. In these studies, the role of the private sector as actors was very small and in some studies it was not explicitly mentioned, while policymakers, who want to move health systems towards UHC must play appropriate roles to provide, identify and rely on private providers and health markets. The importance of strengthening public and private health systems has been repeatedly emphasized in various documents by various international, regional and national institutions related to health care such as WHO, USAID, Global Fund, etc. The non-governmental sector and the private sector, due to their potential and capabilities, can fill the gaps and shortcomings that exist in the public sector, so a serious partnership between them can ultimately increase accountability, equity and efficiency in the health care system. It should be noted that health care outsourced to the private sector in low-and middleincome countries (LMICs) is very widespread, even though weak, and highly heterogeneous. It seems that in EMRO member countries, the role of these two sectors, namely non-governmental organizations and the private sector as a very important player in health system policy, is very small and has led to the lack of progress in existing policies in the health sector.

Limitations
In this context, it seems that the place of the result and the cause of the failure of the programs is empty, and also there are no solutions to the problems in the research. Gilson and Rafaeli pointed out some of the gaps and weaknesses in the analysis of health policies in low-and middle-income countries mentioned in special cases [13].

Conclusion
In the EMRO region, the role of evidence-based research in policy-making has been repeatedly emphasized, but its use in health program decision-making has been limited and health research systems in the EMR are still under scrutiny. We think that they have not been able to produce needed evidence and inject it into health systems. There is still a gap between evidence-based research in health systems and its use in policy-making, as well as in the analysis of health policies in LMICs.
The findings of these studies also confirm this, and therefore studies based on policy analysis should be aimed at achieving this goal because evidence-based decisions can strengthen health systems, improve health and improve existing inequalities. Also, considering that this analysis triangle has 4 specific components, studies should be selected that can be analyzed based on the four elements of this study, but some studies did not have these conditions. On the other hand, this framework should be re-examined and its components should be upto-date and more standardized in order to enable deeper analyses.