Keywords
Abstract
Introduction: Despite all the advantages of urban family physician program (UFPP), there is still a gap between UFPP and what is actually achieved by the community after its implementation in Iran. In response, this study attempted to review published studies related to the barriers to the implementation of the UFPP in Iran as well as potential solutions to improve it. Further, a qualitative study was conducted to learn the perspectives of experts at the national level and in the Fars province in order to better understand the program's challenges.
Methods: This study was conducted in two phases. First, a scoping review was done, aiming to identify the common barriers and potential solutions to implementing UFPP in Iran. Second, a qualitative study using semi-structured interviews was conducted to investigate the views of decision- and policy-makers regarding barriers to and solutions for implementing the UFPP in the Fars province over the last decade. The findings were classified using the five control knobs framework (Organization, financing, payment, regulation, and behavior).
Results: The most common barriers to UFPP were: 1) organization (ununited stewardship function of the Ministry of Health, weak management and planning, inadequate training of human resources, and a weak referral system); 2) financing (fragmented insurance funds, insufficient financial resources, and instability of financial resources); 3) payment (inappropriate payment mechanisms and delay in payments); 4) regulation (cumbersome laws and unclear laws); and 5) behavior (cultural problems and conflict of interests). On the other hand, several solutions were identified to improve the implementation of UFPP, including: enhancing the role of government; improving the referral system; providing comprehensive training for UFPP providers; considering sustainable financial resources; moving towards mixed-payment mechanisms; employing appropriate legal and regulatory frameworks; enhancing community awareness; and elevating incentive mechanisms.
Conclusion: Our research found that, despite the UFPP having been in place for a decade in Iran, there are still significant challenges in all five components. Therefore, the promotion of this program requires solving the existing implementation challenges in order to achieve the predetermined goals. The ideas in this study can be used to improve the current program in Fars Province and bring it to other cities in Iran.
References
Vafaee-Najar A, Nejatzadegan Z, Pourtaleb A, Kaffashi S, Vejdani M, Molavi-Taleghani Y, et al. The quality assessment of family physician service in rural regions, Northeast of Iran in 2012. Int J Health Policy Manag 2014, 2(3):137.
Murray CJ, Frenk J. A framework for assessing the performance of health systems. Bull World Health Organ 2000, 78:717-731.
Walley J, Lawn JE, Tinker A, De Francisco A, Chopra M, Rudan I, et al. Primary health care: making Alma-Ata a reality. Lancet 2008, 372(9642):1001-1007.
Ghebreyesus TA. All roads lead to universal health coverage. Lancet Glob Health 2017, 5(9):e839-e840.
Evans DB, Hsu J, Boerma T. Universal health coverage and universal access. In., vol. 91: SciELO Public Health; 2013: 546-546A.
Sanders D, Nandi S, Labonté R, Vance C, Van Damme W. From primary health care to universal health coverage—one step forward and two steps back. Lancet 2019, 394(10199):619-621.
Doshmangir L, Bazyar M, Doshmangir P, Mostafavi H, Takian A. Infrastructures Required for the Expansion of Family Physician Program to Urban Settings in Iran. Arch Iran Med 2017, 20(9):589-597.
Amiri M, Raei M, Chaman R, Nasiri E. Family physician: The mutual satisfaction of physicians and health care team members. Razi Journal of Medical Sciences 2012, 18(92):23-30.
Mohammadibakhsh R, Aryankhesal A, Jafari M, Damari B. Family physician model in the health system of selected countries: A comparative study summary. J Educ Health Promot 2020, 9:160.
Khayyati F, Motlagh ME, Kabir MJ, Kazemeini H, Gharibi F, Jafari N. The Role of Family Physician in Case Finding, Referral, and Insurance Coverage in the Rural Areas. Iran J Public Health 2011, 40(3):136-139.
Majdzadeh R. Family physician implementation and preventive medicine; opportunities and challenges. Int J Prev Med 2012, 3(10):665-669.
Dewulf B, Neutens T, De Weerdt Y, Van de Weghe N. Accessibility to primary health care in Belgium: an evaluation of policies awarding financial assistance in shortage areas. BMC Fam Pract 2013, 14(1):1-13.
Himmel W, Dieterich A, Kochen MM. Will German patients accept their family physician as a gatekeeper? J Gen Intern Med 2000, 15(7):496-502.
Arab M, Torabipour A, Rahimifrooshani A, Rashidian A, Fadai N. Factors affecting family physicians’ drug prescribing: A cross-sectional study in Khuzestan, Iran. Int J Health Policy Manag 2014, 3(7):377-381.
Majdzadeh R. Family physician implementation and preventive medicine; opportunities and challenges. Int J Prev Med 2012, 3(10):665.
Khayatzadeh-Mahani A, Takian A. Family physician program in Iran: considerations for adapting the policy in urban settings. Arch Iran Med 2014, 17(11):776-778.
Kalhor R, Azmal M, Kiaei MZ, Eslamian M, Tabatabaee SS, Jafari M. Situational analysis of human resources in family physician program: survey from iran. Mater Sociomed 2014, 26(3):195-197.
Mohaghegh B, Seyedin H, Rashidian A, Ravaghi H, Khalesi N, Kazemeini H. Psychological factors explaining the referral behavior of Iranian family physicians. Iran Red Crescent Med J 2014, 16(4):e13395.
Majidi A, Loori N, Shahandeh K, Jamshidi E, Majdzadeh R. Are people in Tehran prepared for the family physician program? Int J Prev Med 2014, 5(8):984-991.
Takian A, Doshmangir L, Rashidian A. Implementing family physician programme in rural Iran: exploring the role of an existing primary health care network. Fam Pract 2013, 30(5):551-559.
Ezatollah G, Mahmood M, Mahammadreza A, Nader A. Challenges in second level of referral system in family physician plan: a qualitative research. 2012.
Yazdi-Feyzabadi V, Delavari S, Ghasemi S. Primary care in Iran needs a paradigm shift. Br J Gen Pract 2018, 68(670):235-235.
Behzadifar M, Behzadifar M, Heidarvand S, Gorji HA, Aryankhesal A, Taheri Moghadam S, et al. The challenges of the family physician policy in Iran: a systematic review and meta-synthesis of qualitative researches. Fam Pract 2018, 35(6):652-660.
Honarvar B, Lankarani KB, Ghahramani S, Akbari M, Tabrizi R, Bagheri Z, et al. Satisfaction and Dissatisfaction Toward Urban Family Physician Program: A Population Based Study in Shiraz, Southern Iran. Int J Prev Med 2016, 7:3.
Sarvestani RS, Kalyani MN, Alizadeh F, Askari A, Ronaghy H, Bahramali E. Challenges of Family Physician Program in Urban Areas: A Qualitative Research. Arch Iran Med 2017, 20(7):446-451.
Naderimagham S, Jamshidi H, Khajavi A, Pishgar F, Ardam A, Larijani B, et al. Impact of rural family physician program on child mortality rates in Iran: a time-series study. Popul Health Metr 2017, 15(1):21.
Khayyati F, Motlagh ME, Kabir M, Kazemeini H, Gharibi F, Jafari N. The role of family physician in case finding, referral, and insurance coverage in the rural areas. Iran J Public Health 2011, 40(3):136-139.
Kolozsvári LR, Orozco-Beltran D, Rurik I. Do family physicians need more payment for working better? Financial incentives in primary care. Atención Primaria 2014, 46(5):261-266.
Fardid M, Jafari M, Vosoogh-Moghaddam A. A policy brief on improving the finance of family physician program: An experience from urban areas of Iran. J Family Med Prim Care 2020, 9(3):1413-1417.
Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D,et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med 2018, 169(7):467-473.
Arksey H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol 2005, 8(1):19-32.
Anderson R. Thematic content analysis (TCA). Descriptive presentation of qualitative data 2007:1-4.
Roberts MJ, Hsiao W, Berman P, Reich MR. Getting health reform right: a guide to improving performance and equity. New York 2008.
Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol 2013, 13(1):1-8.
Abedi G, Marvi A, Soltani Kentaie SA, Abedini E, Asadi Aliabadi M, Safizadehe Chamokhtari K, et al. Swot analysis of implementation of urban family physician plan from the perspective of beneficiaries: A qualitative study. J Maz Univ Med Sci 2017, 27(155):79-93.
Lankarani KB, Alavian SM, Haghdoost AA. Family physicians in Iran: success despite challenges. Lancet 2010, 376(9752):1540-1541.
Bayati M, Keshavarz K, Lotfi F, KebriaeeZadeh A, Barati O, Zareian S, et al. Effect of two major health reforms on health care cost and utilization in Fars Province of Iran: family physician program and health transformation plan. BMC Health Serv Res 2020, 20(1):382.
Bayati M, Rashidian A, Yazdi-Feyzabadi V, Delavari S. Influencing factors on the tendency of general practitioners to join in urban family physician program: a cross-sectional survey on Iranian physicians. Cost Eff Resour Alloc 2022, 20(1):41.
Dehnavieh R, Kalantari AR, Jafari Sirizi M. Urban family physician plan in Iran: challenges of implementation in Kerman. Med J Islam Repub Iran 2015, 29:303.
Delgoshaei B, Vatankhah S, Sarabandi A. Performance payment challenges for family physician program. J Educ Health Promot 2020, 9:225.
Doshmangir L, Rashidian A, Takian A, Doshmangir P, Mostafavi H. Payment system of urban family physician programme in the Islamic Republic of Iran: is it appropriate? East Mediterr Health J 2018, 24(7):611-617.
Esmaeili R, Hadian M, Rashidian A, Shariati M, Ghaderi H. The Experience of Risk-Adjusted Capitation Payment for Family Physicians in Iran: A Qualitative Study. Iran Red Crescent Med J 2016, 18(4):e23782.
Fararouie M, Nejat M, Tabatabaie HR, Kazerooni PA, Akbarpoor M. Satisfaction levels with family physician services: a pilot national health programme in the Islamic Republic of Iran. East Mediterr Health J 2017, 23(4):267-273.
Fardid M, Jafari M, Moghaddam AV, Ravaghi H. Challenges and strengths of implementing urban family physician program in Fars Province, Iran. J Educ Health Promot 2019, 8:36.
Farzadfar F, Jafari S, Rahmani K, Valiee S, Bidarpour F, Molasheikhi M, et al. Views of managers, health care providers, and clients about problems in implementation of urban family physician program in Iran: A qualitative study. J Kurdistan Univ Medical Sci 2017, 22(5):66-83.
Gharibi F, Dadgar E. Pay-for-performance challenges in family physician program. Malays Fam Physician 2020, 15(2):19-29.
Hajibadali P, Nadrian H, Hashemiparast M. Challenges of Implementing Family Physician Program in Urban Communities: A qualitative study. 2022.
Homaie Rad E, Delavari S, Aeenparast A, Afkar A, Farzadi F, Maftoon F. Does Economic Instability Affect Healthcare Provision? Evidence Based on the Urban Family Physician Program in Iran. Korean J Fam Med 2017, 38(5):296-302.
Imanieh MH, Mirahmadizadeh A, Imani B. Factors affecting public dissatisfaction with urban family physician plan: A general population based study in Fars Province. Electron Physician 2017, 9(11):5676-5681.
Kabir MJ, Hassanzadeh-Rostami Z, Ashrafian Amiri H, Nasrollapour Shirvani SD, Keshavarzi A, Hosseini S. Family Physicians' satisfaction with factors affecting the dynamism of the urban family physician program in the Fars and Mazandaran provinces of Iran. Malays Fam Physician 2019, 14(3):28-36.
Kabir MJ, Ashrafian Amiri H, Rabiee SM, Hassanzadeh-Rostami Z, Farzin K, Nasrollahpour Shirvani SD, et al. Level of familiarity and attitude of the covered population regarding the criteria and requirements of Iran's urban family physician program. J Babol Univ Medical Sci 2018, 20(11):40-48.
Jahromi VK, Dehnavieh R, Mehrolhassani MH, Anari HS. Access to Healthcare in Urban Family Physician Reform from Physicians and Patients' Perspective: a survey-based project in two pilot provinces in Iran. Electron Physician 2017, 9(1):3653-3659.
Jahromi VK, Mehrolhassani MH, Dehnavieh R, Anari HS. Continuity of Care Evaluation: The View of Patients and Professionals about Urban Family Physician Program. Int J Prev Med 2017, 8:7.
Mehrolhassani MH, Jahromi VK, Dehnavieh R, Iranmanesh M. Underlying factors and challenges of implementing the urban family physician program in Iran. BMC Health Serv Res 2021, 21(1):1336.
Nasrollahpour Shirvani SD, Mikaniki E, Ashrafian Amiri H, Kabir MJ, Jafari N, Tahmasbi B, et al. Evaluation of the referral system situation in family physician program in Northern provinces of Iran: 2012-2013. J Maz Univ Med 2014, 24(109):27-35.
Ranjbar Ezatabadi M, Rashidian A, Shariati M, Rahimi Foroushani A, Akbari Sari A. Using Conjoint Analysis to Elicit GPs' Preferences for Family Physician Contracts: A Case Study in Iran. Iran Red Crescent Med J 2016, 18(11):e29194.
Sabet Sarvestani R, Najafi Kalyani M, Alizadeh F, Askari A, Ronaghy H, Bahramali E. Challenges of Family Physician Program in Urban Areas: A Qualitative Research. Arch Iran Med 2017, 20(7):446-451.
Safarpour AR, Zarshenas L, Jaberi A, Imanieh MH, Mehrabi M. Developing urban family physician program in Shiraz, Fars province, the doctors’ experiences: A qualitative research. SHIRAZ E-MED J 2020, 21(1).
Chamokhtari KS, Abedi G, Marvi A. Analysis of the patient referral system in urban family physician program, from stakeholders` perspective using SWOT approach: A qualitative study. J Maz Univ Med 2018, 28(161):75-87.
Sepehri B, Ghaffari R, Jeddian A, Salek F, Emrouzi R, Ghaffarifar S, et al. A descriptive-comparative study of implementation and performance of family physician program in Iran and selected countries. Iran J Public Health 2020, 49(3):539-548.
Shahabianmoghaddam A, Baygi MZ. Explaining the Role of Physicians in Urban Comprehensive Health Service Centers After Implementing Health Transformation Plan in Southeast of Iran: A Qualitative Study. Health Scope 2022, 11(1).
Shiraly R, Mahdaviazad H, Pakdin A. Doctor-patient communication skills: a survey on knowledge and practice of Iranian family physicians. BMC Fam Pract 2021, 22(1):130.
Sokhanvar M, Kabir MJ, Bevrani H, Nosratnejad S, Janati A, Hasanpoor E. Family physician and referral system adherence in iranian primary healthcare system. Fam Med Prim Care Rev 2020, 22(2):158-165.
Tavakoli F, Nasiripour AA, Riahi L, Mahmoudi M. Design of a Model for Management of Referral System in the Iranian Urban Family Physician Program. Iran J Public Health 2020, 49(11):2144-2151.
Yazdi Feyzabadi V, Mehrolhassani MH, Baneshi MR, Mirzaei S, Oroomiei N. Association between pilot urban family physician program and health financial protection measures in fars and Mazandaran provinces. Iran J Epidemiology 2018, 13(5):48-58.
Honarvar B, Lankarani KB, Rostami S, Honarvar F, Akbarzadeh A, Odoomi N, et al. Knowledge and Practice of People toward their Rights in Urban Family Physician Program: A Population-Based Study in Shiraz, Southern Iran. Int J Prev Med 2015, 6:46.
Honarvar B, Lankarani KB, Kazemi M, Shaygani F, Sekhavati E, Raooufi A, et al. Five Years after Implementation of Urban Family Physician Program in Fars Province of Iran: Are People's Knowledge and Practice Satisfactory? Int J Prev Med 2018, 9:41.
Brinkerhoff DW, Cross HE, Sharma S, Williamson T. Stewardship and health systems strengthening: An overview. Public Adm Dev 2019, 39(1):4-10.
Saltman RB, Ferroussier-Davis O. The concept of stewardship in health policy. Bull World Health Org 2000, 78(6):732-739.
Doshmangir L, Bazyar M, Najafi B, Haghparast-Bidgoli H. Health financing consequences of implementing health transformation plan in Iran: achievements and challenges. Int J Health Policy Manag 2019, 8(6):384.
Damari B. Challenges and directions of public health development in Iran from the viewpoint of provincial health deputies and health center. Journal of School of Public Health and Institute of Public Health Research 2015, 13(1):1-16.
Kabir MJ, Heidari A, Honarvar MR, Khatirnamani Z, Rafiei N. Challenges in the implementation of an electronic referral system: A qualitative study in the Iranian context. Int J Health Plann Manage.
Anbari Z, Mohammadbeigi A, Mohammadsalehi N, Ebrazeh A. Health expenditure and catastrophic costs for inpatient-and out-patient care in Iran. Int J Prev Med 2014, 5(8):1023.
Doshmangir L, Bazyar M, Doshmangir P, Mostafavi H, Takian A: Infrastructures required for the expansion of family physician program to urban settings in Iran. Arch Iran Med 2017, 20(9):-.
Yazdi Feyzabadi V, Khosravi S, Amiresmaili M. Performance evaluation of rural family physician plan: a case of Kerman University of Medical Sciences. Tolooebehdasht 2014, 12(4):48-59.
Gosden T, Forland F, Kristiansen I, Sutton M, Leese B, Giuffrida A, et al. Capitation, salary, fee‐for‐service and mixed systems of payment: effects on the behaviour of primary care physicians. Cochrane Database Syst Rev 2000(3).
Arab M, Torabipour A, Rahimifrooshani A, Rashidian A, Fadai N, Askari R. Factors affecting family physicians' drug prescribing: a cross-sectional study in Khuzestan, Iran. Int J Health Policy Manag 2014, 3(7):377-381.
Olyaeemanesh A, Behzadifar M, Mousavinejhad N, Behzadifar M, Heydarvand S, Azari S, et al. Iran’s health system transformation plan: a SWOT analysis. Med J Islam Repub Iran 2018, 32:39.
Janati A, Maleki MR, Gholizadeh M, Narimani M, Vakili S: Assessing the strengths & weaknesses of family physician program. 2010.