Background The health research system (HRS) is an important national priority that requires a systematic and functional approach. Evaluating the HRS of Iran as a developing country and identifying its challenges reveals the stewardship-related role in how the whole system is operating well. This study aims to assess the HRS in terms of stewardship functions and highlight the enhancement points. Methods This study was carried out between March 2020 and April 2021 using a systematic review and meta-synthesis of evidence to examine the Iranian HRS stewardship challenges and interview 32 stakeholders, using a critical case sampling and snowballing approach which included both semi-structured and in-depth interviews. The interviewees were selected based on criteria covering policy-makers, managers, research bodies and nongovernmental organizations (NGOs) in health research-related fields like higher education, research, technology, innovation and science. All data were analysed using content analysis to determine eight main groups of findings under three levels: macro, meso, and micro. Results Analysis of the findings identified eight main themes. The most critical challenges were the lack of an integrated leadership model and a shared vision among different HRS stakeholders. Their scope and activities were often contradictory, and their role was not clarified in a predetermined big picture. The other challenges were legislation, priority-setting, monitoring and evaluation, networking, and using evidence as a decision support base. Conclusions Stewardship functions are not appropriately performed and are considered the root causes of many other HRS challenges in Iran. Formulating a clear shared vision and a work scope for HRS actors is critical, along with integrating all efforts towards a unified strategy that assists in addressing many challenges of HRS, including developing strategic plans and future-oriented and systematic research, and evaluating performance. Policy-makers and senior managers need to embrace and use evidence, and effective networking and communication mechanisms among stakeholders need to be enhanced. An effective HRS can be achieved by redesigning the processes, regulations and rules to promote transparency and accountability within a well-organized and systematic framework.

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Background: The health research system is an important national priority that requires a systematic and functional approach. Evaluating the HRS of Iran, as a developing country, and identifying its challenges show the significant role of the stewardship-related ones in how the whole system is operating well. The study aims to assess the health research system regarding stewardship functions and highlighting the enhancement points. Methods: This study was carried out between March 2020 to April 2021 using a systematic review and meta-synthesizing of evidence to examine the Iranian HRS stewardship challenges and interview 42 stakeholders, using a critical case sampling and snowballing approach that some were semi-structured and some in-depth. The interviewees were selected criteria-based, covering the policymakers, managers, research bodies, and NGOs in health research-related fields like higher education, research, technology, innovation, and science. All data were analyzed using the content analysis leading to determining eight main groups of findings under three levels of Macro, Meso, and Micro.Results: Analyzing the findings leads to eight main themes. The most critical challenges were: not forming an integrated leadership model, and a shared vision among different HRS stakeholders. Their scope and activities had contradictions, and their role was not clarified in a predetermined big picture. The other challenges were in legislation, priority setting, monitoring and evaluation, networking, and using evidence as a decision support base.Conclusion: Stewardship functions are inappropriately performed, and they are considered the root causes of many other HRS challenges in Iran. Formulating a clear shared vision and formulating the work scope for HRS actors is critical, along with integrating all efforts toward a unified strategy that assists in addressing many challenges of HRS. Developing strategic plans, future-oriented and systematic research, and evaluating the performances. Policymakers and senior managers need to embrace and use evidence, and effective networking and communication mechanisms among stakeholders need to be enhanced. To have an effective HRS, redesigning the processes, regulations, and rules promotes transparency, accountability, being well-organized and systematic.