Barriers and challenges of establishing family physician policy for urban population; evidence from a qualitative study in Iran
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Keywords

Family Physician, scoping review, qualitative study, Iran

Abstract

Background: Family physicians hold a central role within the healthcare service delivery systems of most nations. In the context of Iran, although the family physician program has been introduced in only two provinces, its expansion to other provinces has encountered certain obstacles and is presently suspended. This study is centered on elucidating the barriers and challenges that hinder the effective implementation of the family physician program in urban areas of Iran. Methods: The qualitative nature of this study dictated the selection of participants via purposeful sampling, comprising health system policy-makers, senior administrators, and physicians. To gather the insights of these experts, a semi-structured interview approach was employed. The interviewing process persisted until data saturation was achieved, yielding a total of 32 participants. Analytically, the grounded theory approach was employed to meticulously analyze the collected data. This involved the formulation of open and axial codes, subsequently progressing to selective coding, which facilitated the identification of overarching themes and corresponding sub-themes. Results: The preeminent challenge encountered in the endeavor to implement the urban family physician program was ascribed to conflicting interests among stakeholders, a challenge that occupied the central position as the core category. Delving deeper, factors precipitating this challenge included the intricacies of the payment mechanism, and contextual variables encompassing stewardship, structural intricacies, financial considerations, and cultural elements. The main stakeholders, including specialist physicians, reacted resistance against the implementation. Reverse referral was also another coping strategy by specialist physicians. This collective array of factors coalesced to thwart the nationwide rollout of the policy initiative. Conclusions: The resolution of the impediments to implementing urban family physician policies necessitates a comprehensive re-evaluation of stakeholders and restructuring of payment system. Furthermore, proactive efforts towards resolving the intricate contextual challenges within the healthcare system are imperative to facilitate the successful implementation of these policies.
https://doi.org/10.15167/2421-4248/jpmh2024.65.3.3346
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References

Verulava T, Dangadze B, Jorbenadze R, Lordkipanidze A, Karimi L, Eliava E, et al. The Gatekeeper Model: patient’s view on the role of the family physician. 2020. doi: 10.5114/fmpcr.2020.92511

Starfeld B. Improving equity in health: a research agenda. Int J Health Serv. 2001;31(3):545–66. doi:10.2190/dgj8-4mqw-up9j-lqc1

Gossa W, Wondimagegn D, Demeke Mekonnen WE, Abebe Z, Fetters MD. Key informants’ perspectives on development of Family Medicine training programs in Ethiopia. Advances in medical education and practice. 2016;7:261. doi:10.2147/AMEP.S94522

van der Voort CT, van Kasteren G, Chege P, Dinant G-J. What challenges hamper Kenyan family physicians in pursuing their family medicine mandate? A qualitative study among family physicians and their colleagues. BMC family practice. 2012;13(1):32. doi:10.1186/1471-2296-13-32

De Maeseneer J, Flinkenflögel M. Primary health care in Africa: do family physicians fit in? British Journal of General Practice. 2010;60(573):286-92. doi:10.3399/bjgp10X483977

Stavdal, Anna & Flegg, Karen & Li, Donald & Lygidakis, Harris & Wass, Val & Pena, Maria & Moosa, Shabir & Abubakar, Dan & Jamal, Mohammad & Farhat, Taghreed & Vinker, Shlomo & Ponzo, Jacqueline & Markuns, Jeff & Aziz, Tarıq & Randenikumara, Sankha & Gokdemir, Ozden & Barros, Enrique. (2023). WONCA FINAL ANNUAL REPORT 2022.

Manca DP, Varnhagen S, Brett-MacLean P, Allan GM, Szafran O, Ausford A, et al. Rewards and challenges of family practice: Web-based survey using the Delphi method. Canadian Family Physician. 2007;53(2):277-86. PMID: 17872645; PMCID: PMC1949127.

Sklar M, Seijo C, Goldman RE, Eaton CB. Beyond checkboxes: A qualitative assessment of physicians' experiences providing care in a patient‐centred medical home. Journal of evaluation in clinical practice. 2019. doi:10.1111/jep.13136

Budi RS, Adisasmito WBB. Implementation of the primary health care system in various countries: a systematic review. BKM Public Health and Community Medicine. 2023;39(04):e7168-e. doi:10.22146/bkm.v39i04.7168

Mohammadibakhsh R, Aryankhesal A, Sohrabi R, Alihosseini S, Behzadifar M. Implementation Challenges of Family Physician Program: A Systematic Review on Global Evidence. Medical Journal of the Islamic Republic of Iran. 2023;37. doi: 10.47176/mjiri.37.21

Damari B, Vosough Moghaddam A, Rostami Gooran N, Kabir MJ. Evaluation of the Urban Family Physician and Referral System Program in Fars and Mazandran Provinces: History, Achievements, Challenges and Solutions. Journal of School of Public Health and Institute of Public Health Research. 2016;14(2):17-38.

Fardid M, Jafari M, Moghaddam AV, Ravaghi H. Challenges and strengths of implementing urban family physician program in Fars Province, Iran. Journal of education and health promotion. 2019;8. doi: 10.4103/jehp.jehp_211_18

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. Family practice. 2018. doi:10.1093/fampra/cmy035

Candela AG. Exploring the function of member checking. The Qualitative Report. 2019;24(3):619-28. doi:10.46743/2160-3715/2019.3726

Corbin J, Strauss A. Basics of qualitative research: Techniques and procedures for developing grounded theory: Sage publications; 2015.

Aftab W, Siddiqui FJ, Tasic H, Perveen S, Siddiqi S, Bhutta ZA. Implementation of health and health-related sustainable development goals: progress, challenges and opportunities–a systematic literature review. BMJ global health. 2020;5(8):e002273. doi:10.1136/bmjgh-2019-002273

Naseriasl, Mansour & Amini, Abolghasem & Doshmangir, Leila & Adham, Davoud & Janati, Ali. (2018). Challenges of establishing specialty referral system in iran's health sector (a qualitative study). 10.19193/0393-6384_2017_1s_137. doi:10.19193/0393-6384_2017_1s_137

Alinia, C., Takian, A., Saravi, N. et al. Physician induced demand for knee replacement surgery in Iran. BMC Health Serv Res 21, 763 (2021). doi: 10.1186/s12913-021-06697-6

Etemadi M, Ashtarian K, Ganji N. A model of financial support for the poor to access health services in Iran: Delphi technique. International Journal of Health Governance. 2023;28(2):165-78. doi: 10.1108/IJHG-07-2022-0071

Seyedin H, Afshari M, Isfahani P, Rakhshan A, Hasanzadeh E, Taherimirghaed M. Main Factors leading to supplier-induced demand in Iran: A comprehensive review. Health Scope. 2020;9(2). doi: 10.5812/jhealthscope.96366

Daminabo B, Ajao E. Factors influencing the utilisation of the referral system in selected primary health care centres among nurses in Rivers State, Nigeria. International Journal of Academic Research in Business, Arts and Science. 2020;2(5):28-39. doi:10.5281/zenodo.3819581

Nasseh K, Vujicic M, Yarbrough C. A ten-year, state-by-state, analysis of Medicaid fee-for-service reimbursement rates for dental care services. Am Dent Assoc. 2014;20:21.

Rafiei N, Vatankhah S, Kabir MJ. Primary care physician payment mechanisms toward universal health coverage: A study of Iran and selected countries. The International Journal of Health Planning and Management. 2022;37(1):372-86. doi: 10.1002/hpm.3340

Martin B, Jones J, Miller M, Johnson-Koenke R. Health Care Professionals’ Perceptions of Pay-for-Performance in Practice: A Qualitative Metasynthesis. INQUIRY: The Journal of Health Care Organization, Provision, and Financing. 2020;57:0046958020917491. doi:10.1177/004695802091749

Doshmangir L, Bazyar M, Doshmangir P, Mostafavi H, Takian A. Infrastructures Required for the Expansion of Family Physician Program to Urban Settings in Iran. Archives of Iranian Medicine (AIM). 2017;20(9). PMID: 29048921

Khayatzadeh-Mahani A, Sedoghi Z, Mehrolhassani MH, Yazdi-Feyzabadi V. How Health in All Policies are developed and implemented in a developing country? A case study of a HiAP initiative in Iran. Health promotion international. 2016;31(4):769-81. doi: 10.1093/heapro/dav062

Lankarani KB, Honarvar B, Shahabi S, Zarei F, Behzadifar M, Hedayati M, et al. The challenges of urban family physician program over the past decade in Iran: a scoping review and qualitative study with policy-makers. Journal of Preventive Medicine and Hygiene. 2023;64(2):E232. doi: 10.15167/2421-4248/jpmh2023.64.2.3029.

Shams L, Nasiri T, Amiri MM, Abdolahi Z. Challenges of rural family physician policy in Iran. International Journal of Preventive Medicine. 2023;14. doi: 10.4103/ijpvm.ijpvm_24_22

Luo L, Zhang S, Xiang J. Development of the family doctor service: an evolutionary game theory analysis. Economic Research-Ekonomska Istraživanja. 2023;36(2):2106507. doi: 10.1080/1331677X.2022.2106507

Yuan S, Wang F, Li X, Jia M, Tian M. Facilitators and barriers to implement the family doctor contracting services in China: findings from a qualitative study. Bmj Open. 2019;9(10). doi: 10.1136/bmjopen-2019-032444

Mohammadibakhsh R, Aryankhesal A, Jafari M, Damari B. Family physician model in the health system of selected countries: A comparative study summary. Journal of education and health promotion. 2020;9. doi: 10.4103/jehp.jehp_709_19

Dong L, Keshavjee K. Why is information governance important for electronic healthcare systems? A Canadian experience. Journal of Advances in Humanities and Social Sciences. 2016;2(5):250-60. doi: 10.20474/jahss-2.5.1

Nguyen Long LA, Foster M, Arnold G. The impact of stakeholder engagement on local policy decision making. Policy Sciences. 2019;52:549-71. doi:10.1007/s11077-019-09357-z

Behzadifar M, Behzadifar M, Saran M, Shahabi S, Bakhtiari A, Azari S, et al. The role of Iran's context for the development of health technology assessment: challenges and solutions. Health Economics Review. 2023;13(1):23. doi:10.1186/s13561-023-00438-7

Bashar MA, Bhattacharya S, Tripathi S, Sharma N, Singh A. Strengthening primary health care through e-referral system. Journal of family medicine and primary care. 2019;8(4):1511. doi: 10.4103/jfmpc.jfmpc_184_19

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 Services Research. 2020;20(1):1-9. doi:10.1186/s12913-020-05257-8

Kabir MJ, Amiri HA, Hassanzadeh-Rostami Z, Momtahen R, Zafarmand R, Shirvani SDN. Achievements and Challenges in Implementing Urban Family Physician Program in Iran: Viewpoint of Managers and Executives. Quarterly Journal of Management Strategies in Health System. 2019. doi.org/10.18502/mshsj.v4i2.1410

DeCamp M, Pomerantz D, Cotts K, Dzeng E, Farber N, Lehmann L, et al. Ethical issues in the design and implementation of population health programs. Journal of general internal medicine. 2018;33:370-5. doi: 10.1007/s11606-017-4234-4

Alidoost S, Rezapour A, Sohrabi R, Mohammadibakhsh R, Sarabi-Asiabar A, Rafiei N. Causes of revenue deficits of university hospitals and strategies to reduce them. Journal of Hospital. 2019;18(1):67-78.

Arya N, Dahlman B, Gibson C, Ponka D, Haq C, Rouleau K, et al. Developing family practice to respond to global health challenges: The Besrour Papers: a series on the state of family medicine in the world. Canadian Family Physician. 2017;63(8):602-6. PMID: 28807953; PMCID: PMC5555325.

Besigye IK, Onyango J, Ndoboli F, Hunt V, Haq C, Namatovu J. Roles and challenges of family physicians in Uganda: A qualitative study. African journal of primary health care & family medicine. 2019;11(1):1-9. doi:10.4102/phcfm.v11i1.2009

Moghri J, Arabloo J, Rahatlou MB, Saadati M, Yousefzadeh N. Current knowledge of physicians’ dual practice in Iran: A scoping review and defining the research agenda for achieving universal health coverage. PloS one. 2022;17(11):e0277896. doi: 10.1371/journal.pone.0277896

Bayat M, Shokri A, Khodadost M, Fattahi H, Mirbahaeddin E, Harirchi I, et al. Factors influencing medical specialists’ dual practice in the Islamic Republic of Iran. EMHJ. 2018;24(9-2018). doi: 10.26719/2018.24.9.877

Raeisi AR, Yarmohammadian MH, Mohammadibakhsh R, Gangi H. Determining the performance indicators based on Iranian balanced scorecard model in AL-Zahra Hospital of Isfahan University of Medical Science. Health Information Management. 2013;10(4):601-10.