Dear Editor
Health governance is recognized as one of the fundamental pillars of modern healthcare systems. This concept refers to the set of structures, processes, and norms that guide decision-making, resource allocation, and service delivery in the health sector [1]. Health governance is an interdisciplinary field that uses knowledge from social, political, legal, economic, and ethical sciences to provide appropriate solutions for improving health and enhancing efficiency, transparency, accountability, and equity in the health sector. When designed and implemented transparently, participatively, and responsibly, health governance can increase the legitimacy of health policies, strengthen equitable access to services, and improve resource utilization efficiency. In this way, not only does the quality of healthcare services improve, but both individual and social health outcomes are also enhanced. In the current context, where health systems face challenges, such as emerging pandemics, climate change, demographic inequalities, and limitations in human and financial resources, the importance of efficient governance is more critical than ever [2]. On the other hand, effective governance creates the necessary foundation for sustainability, resilience, and responsiveness to the changing needs of populations. 
One of the major challenges in health systems, especially in developing countries, like Iran, is the fragmentation of governance structures. In many cases, tasks related to prevention, treatment, policymaking, and regulation are dispersed among various institutions that lack the necessary coordination [3]. This fragmentation leads to inefficiencies, such as overlapping responsibilities, confusion of roles, and conflicts in goals and priorities. In Iran’s health sector, the prevailing model remains a centralized and hierarchical governance system, organized in a top-down manner, and lacking the necessary platforms for collaboration and learning among various stakeholders. This centralization causes marginalized and underdeveloped regions to be excluded from the policymaking process, increasing inequalities in access to services. In contrast, polycentric governance, which focuses on distributing decision-making power and empowering actors, offers greater flexibility and efficiency to the system. This type of governance is especially important in the context of complex adaptive systems, of which the health system is a prime example. In such systems, different actors are constantly interacting, and a change in the behavior of one can have unpredictable effects on other sectors. Therefore, only structures capable of learning, adapting, and self-organization can perform effectively in the face of such complexities.
Polycentric governance is not only a model for distributing power and responsibility but also a mechanism to enhance the resilience of health systems against unforeseen risks and crises [4]. As the pace of emerging threats, such as new diseases, environmental pollution, and natural disasters, increases, health systems require structures that can respond quickly and locally. Hierarchical and centralized models, due to their slow decision-making and lack of flexibility, are ineffective in tackling these challenges. In contrast, polycentric governance, by providing space for innovation, experience exchange, organizational learning, and utilizing diverse resources, can increase the effectiveness of risk management actions [5]. This model, which allows for testing various solutions and actively involves the community, significantly enhances the system’s ability to adapt in unstable and crisis situations. Decentralization in health governance has been shown in various settings to improve responsiveness, local accountability, and equitable resource distribution, although it also presents challenges, such as capacity variation among local actors and risks of coordination failures. In other words, decentralization in health governance is not just a managerial decision but a strategic approach to addressing a complex and high-risk future. Therefore, in designing health governance structures, there should be a shift toward developing flexible, collaborative, polycentric models that can align diverse interests, optimally distribute resources, and empower the system to confront emerging risks. 
In Iran, despite progressive health initiatives, persistent fragmentation and centralization continue to limit equity and service efficiency, especially in marginalized regions. Embracing a polycentric governance approach, which decentralizes decision-making and fosters collaboration among stakeholders, offers a strategic pathway to address these systemic challenges and build a more resilient and equitable health system that is responsive to emerging risks and local needs.




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