Agenda-Setting for Sustainable Financing of Medical Education: A Mixed-Methods Policy Analysis Using Multiple Streams and Policy Triangle Frameworks

Introduction: Sustainable financing of medical education is critical to health workforce development and health system performance. While existing research has largely examinedfinancing 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 sameexpert 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 threestreams 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- andmiddle-income countries facing similar structural constraints.