Population ageing in Iran increases demand for exercise and health-based services for older adults and creates new planning challenges for the health system. The study aimed to identify and analyses the drivers that shape the future of such services in Iran. A structural analysis design combined a review of literature and policy documents with a Delphi process and MICMAC analysis. The PESTEL-based review generated an initial pool of drivers, and an expert panel in geriatric care, rehabilitation, public health and health services management refined and validated 18 drivers. Experts rated the importance of each driver, and all drivers reached high consensus levels. The panel then completed an 18‌×‌18 cross-impact matrices using the MICMAC influence scale, and software produced influence and dependence scores, rankings and graphical maps. Results showed a mixed pattern with a small group of highly influential drivers and several strongly dependent variables. Integration of elder exercise into clinical guidelines, policy priority, stable funding, insurance coverage and affordability, technological access and availability of age-friendly primary care, and rehabilitation centers showed high influence. Health literacy, cultural norms, and social and peer support showed high dependence and acted as outcomes of political, financial, technological and environmental conditions. Legal and professional standards held intermediate influence and linked strategic choices with clinical and organizational practice and safety. Overall findings support strategies across sectors that align funding, policy, technology, infrastructure, social support and regulation, strengthen exercise and health-based services and promote active and healthy ageing for older adults in Iran.