This study provides a critical analysis of health related charitable policy making in Iran after the Islamic Revolution. It investigates the reasons behind the declining participation of civil society and philanthropic actors over recent decades, despite rising needs for healthcare and welfare services among vulnerable groups and the state’s limited capacity to meet these demands. The research argues that policy and governance mechanisms have progressively weakened the autonomy of charitable institutions, reduced public trust, and diminished community engagement.

Drawing on Rawls’s theory of justice as fairness, Sen and Nussbaum’s capability approach, and Habermas’s theory of communicative action, the study employs a qualitative critical paradigm. Data were collected through documentary analysis of multiple presidential periods, participant observation, and focus group interviews, and were analyzed using thematic analysis.

Findings indicate that state–charity relations have been shaped by dominant political discourses and hindered by the absence of a stable supportive legal framework. Across most administrations, the state has adopted a controlling or extractive role, limiting the development of autonomy, innovation, and effective contributions by NGOs and charitable organizations within Iran’s health system. These dynamics have constrained their capacity to address social needs and support equitable access to essential services in the country today