TY - JOUR
AU1 - Behzadifar,, Masoud
AU2 - Behzadifar,, Meysam
AU3 - Heidarvand,, Sanaz
AU4 - Gorji, Hasan, Abolghasem
AU5 - Aryankhesal,, Aidin
AU6 - Taheri Moghadam,, Sharare
AU7 - Mohammadibakhsh,, Roghayeh
AU8 - Bragazzi, Nicola, Luigi
AB - Abstract Background A good level of health requires the establishment of primary health care. Family physician policy (FPP) is probably one of such initiatives, which enables societies attaining the universal health coverage. Objective The present study is the first systematic review and meta-synthesis that seeks to provide a more comprehensive understanding of the challenges for FPP in Iran. Method Several international scholarly databases (namely, ISI/Web of Sciences, PubMed/MEDLINE via Ovid, Embase, PsycINFO, Scopus and CINAHL via EBSCO), as well as three Iranian databases [MagIran, Irandoc and Scientific Information Database (SID) databases], were mined from January 2006 to December 2017. The Noblit & Hare approach was used to analyse the selected studies. Results Based on the study inclusion criteria, seven studies were retained. Initially, 133 codes were identified. In the second step, two of the authors examined the codes and merged themes based on their similarities and shared meaning. New codes were created through discussion. In the next and final step, eight themes emerged, namely, (i) financing; (ii) motivational factors; (iii) education; (iv) referral system; (v) performance evaluation; (vi) problems with health policy; (vii) health information system; and (viii) culture-building for proper policy implementation. Conclusion Although more than 10 years have passed since the implementation of FPP in Iran, and despite its positive effects on health, there are still challenges in implementing this policy, which makes it difficult to achieve its objectives. Health decision- and policy-makers in Iran should address these challenges and use all available capacities to face them. Challenges, family physician, Iran, meta-synthesis, systematic review Introduction Living more and better is the ambitious goal of health care plans, worldwide (1). Developing countries are pursuing a variety of policies to reduce poverty and to improve social empowerment of the communities, in order to impact on their health levels and to achieve more progress in the international arena (2). Health is a fundamental human right (3). A good health level across societies requires the establishment of the primary health care (PHC), as emphasized by the World Health Organization (WHO). PHC is defined as the possibility of accessing to a comprehensive package of health services (prevention and health promotion, disease treatment and management, and rehabilitation), which facilitates the achievement of a universal health coverage (UHC) (4,5). As such, a strong network of infrastructures for health services delivery and provision is needed, using appropriate, cost-effective policies. Family physician policy (FPP) enables societies attaining UHC (6). Providing PHC to the population, creating and implementing a referral system, improving payment mechanisms and protecting people against health costs are some of the tasks of FPP (7). Family physicians serving in the FPP act as gatekeepers in the health sector as they screen patients, deciding whether they need to access to more specialized services. This can reduce health costs and lead to better health outcomes (8). Various studies have shown the effectiveness of this programme (9,10), and, as a result, many countries have adopted this policy (11–13). In the Middle East, FPP has been one of the health care policy priorities, even though certain local obstacles and hurdles have hindered a full, successful implementation of the programme (14). Since 1974, Iran has made a major effort to create a health system that can respond to the health needs of individuals. In 1985, the primary health services network was established (15). People from rural areas were selected as ‘Behvarz’, and after 2 years of training, PHC services were provided to communities. This system has significantly improved health indicators in Iran (16). The control of infectious diseases, the decrease of the mortality rate of children and mothers, the increase of life expectancy and the utilization of high-skilled, ad hoc trained human resources have been some of the main strengths of this policy (7). However, over time, the PHC network has lacked appropriate flexibility to meet with the new health needs. Since 2005, the Iranian government has introduced and implemented a family doctor programme (17), both in rural and urban areas, and provided services in the form of a health care team. The first contact points to which patients are referred are health centres, and, if needed, specialist services are introduced using the referral system to specialized physicians and specialized hospitals (18). By implementing FPP as the second major reform in Iran’s health system, community health has significantly improved (19). In addition, the programme has made per capita payments as a preferred payment mechanism to selected service providers and has paid more for physicians working in less developed areas, while also providing access to outpatient care. These have made it possible to reach UHC in Iran in a better and more appropriate way (20). However, any policy plan in the implementation phase may face challenging issues (10,21). Following the implementation of the FPP in Iran, several studies have been conducted to identify major challenges and obstacles. The present study is the first systematic review and meta-synthesis that seeks to provide a comprehensive understanding of the challenges encountered by FPP in Iran. Method This study was registered in PROSPERO (identification number CRD42017075088). Qualitative meta-synthesis studies are aimed at collecting findings from primary qualitative studies related to a given topic (22) and can generate new conceptual tools and theoretical frameworks/models (23,24). The ‘Preferred Reporting Items for Systematic Reviews and Meta-Analyses’ (PRISMA) checklist was followed (25). Several international scholarly databases (namely, ISI/Web of Sciences, PubMed/MEDLINE via Ovid, Embase, PsycINFO, Scopus and CINAHL via EBSCO), as well as three Iranian databases [MagIran, Irandoc and Scientific Information Database (SID) databases], were mined from January 2006 to December 2017. The reference list of included studies was also hand-searched to ensure that all relevant studies were included. The results of searches were handled with Endnote V.X7 software, deleting duplicate studies. Studies were included if published in English and Persian, utilizing qualitative methods and focusing on the challenges and barriers of FPP. Studies were excluded if designed as commentaries, editorials, case reports, cross-sectional studies and PhD Thesis, not describing perspectives, barriers and challenges and/or not utilizing qualitative methods. The assessment of the methodological quality of studies was performed by two authors independently using the ‘Critical Appraisal Skills Programme’ (CASP) checklist (26). Based on their methodological quality, studies were ranked in three categories, namely, low, medium and high quality. The Noblit & Hare approach was used to analyse the selected studies (27). This method comprises three stages: in the first step, after familiarizing with the articles, main categories/themes are extracted, preserving the concepts and meanings of the original studies. In the second stage, by examining concepts, themes and classifications, the relationship between initial data and new interpretations is established. Finally, in the third stage, new interpretations are determined/generated based on the conceptual model of the new themes and their subcategories. For these tasks, MAXQDA Ver11 software was used. Results Systematic literature search Initially, 152 articles were found, and 58 duplicate studies were deleted. A total of 94 articles were screened on the basis of title and/or abstract. In this phase, 59 unrelated studies were removed. Based on full text, 35 studies were reviewed in-depth, and 7 studies finally retained (28–34), as shown in Figure 1. Figure 1. View largeDownload slide Flow chart of the study selection. Figure 1. View largeDownload slide Flow chart of the study selection. Data extraction A total of 119 participants were interviewed in these studies. The main characteristics of these investigations are shown in Table 1. Table 1. Characteristics of included studies First author (reference) Year Study focus/aim/perspective Number of type of participants Data collection method Number of participants Analysis method Study design Mehrolhassani (28) 2012 Challenges of implementing family physician Policy executives/10 Semi-structured focus group 10 Content analysis Qualitative Discussions, audio recorded Arab (29) 2013 Attitude of family physicians working in health and challenges Physicians/33 Semi-structured interviews, 45–60 minutes, focus group 33 Framework method Qualitative Dehnavieh (30) 2015 Implementation challenges of family physician 9 from Kerman University of Medical Science, 5 from health services insurance, 1 from the medical system and 6 experts (4 social physicians and 2 researchers in the field of family physician plan) Semi-structured interviews, audio recorded, 50 minutes, in-depth interview 21 Content analysis Qualitative Esmaeili (31) 2015 Understand the perspectives of policy- and decision-makers of Iran’s health system about the implementation of family medicine Ministry of Health and Medical Education/7 Semi-structured interviews, audio recorded, 50–75 minutes 27 Framework method Qualitative Iranian Health Insurance Organization/3 Medical universities and affiliated research centres/10 Iran Medical Council/2 Executive Directors in Pilot Provinces/5 Nejatzadegan (32) 2016 Challenges in the rural family doctor system Physicians enrolling in family physician programmes/8 Semi-structured interviews, audio recorded, 40–70 minutes, in-depth interview 21 Content analysis Qualitative Directors of physician programme/13 Shiyani (33) 2016 Challenges of family physician implementation Former Health Minister/2 Semi-structured interviews, audio recorded 23 Content analysis Qualitative Country Policymakers/11 Directors of physician programme/3 Directors of the Insurance Referral Center/2 Health experts/1 Deputy Health of Medical of University/2 Experts Family Physician Program/2 Sabet Sarvestani (34) 2017 Challenges of family physician Physicians enrolling in family physician programme/10 Semi-structured interviews, audio recorded, 60–90 minutes 17 Content analysis Qualitative Medical specialists/4 Pharmacists/2 Pathologist/1 First author (reference) Year Study focus/aim/perspective Number of type of participants Data collection method Number of participants Analysis method Study design Mehrolhassani (28) 2012 Challenges of implementing family physician Policy executives/10 Semi-structured focus group 10 Content analysis Qualitative Discussions, audio recorded Arab (29) 2013 Attitude of family physicians working in health and challenges Physicians/33 Semi-structured interviews, 45–60 minutes, focus group 33 Framework method Qualitative Dehnavieh (30) 2015 Implementation challenges of family physician 9 from Kerman University of Medical Science, 5 from health services insurance, 1 from the medical system and 6 experts (4 social physicians and 2 researchers in the field of family physician plan) Semi-structured interviews, audio recorded, 50 minutes, in-depth interview 21 Content analysis Qualitative Esmaeili (31) 2015 Understand the perspectives of policy- and decision-makers of Iran’s health system about the implementation of family medicine Ministry of Health and Medical Education/7 Semi-structured interviews, audio recorded, 50–75 minutes 27 Framework method Qualitative Iranian Health Insurance Organization/3 Medical universities and affiliated research centres/10 Iran Medical Council/2 Executive Directors in Pilot Provinces/5 Nejatzadegan (32) 2016 Challenges in the rural family doctor system Physicians enrolling in family physician programmes/8 Semi-structured interviews, audio recorded, 40–70 minutes, in-depth interview 21 Content analysis Qualitative Directors of physician programme/13 Shiyani (33) 2016 Challenges of family physician implementation Former Health Minister/2 Semi-structured interviews, audio recorded 23 Content analysis Qualitative Country Policymakers/11 Directors of physician programme/3 Directors of the Insurance Referral Center/2 Health experts/1 Deputy Health of Medical of University/2 Experts Family Physician Program/2 Sabet Sarvestani (34) 2017 Challenges of family physician Physicians enrolling in family physician programme/10 Semi-structured interviews, audio recorded, 60–90 minutes 17 Content analysis Qualitative Medical specialists/4 Pharmacists/2 Pathologist/1 View Large Table 1. Characteristics of included studies First author (reference) Year Study focus/aim/perspective Number of type of participants Data collection method Number of participants Analysis method Study design Mehrolhassani (28) 2012 Challenges of implementing family physician Policy executives/10 Semi-structured focus group 10 Content analysis Qualitative Discussions, audio recorded Arab (29) 2013 Attitude of family physicians working in health and challenges Physicians/33 Semi-structured interviews, 45–60 minutes, focus group 33 Framework method Qualitative Dehnavieh (30) 2015 Implementation challenges of family physician 9 from Kerman University of Medical Science, 5 from health services insurance, 1 from the medical system and 6 experts (4 social physicians and 2 researchers in the field of family physician plan) Semi-structured interviews, audio recorded, 50 minutes, in-depth interview 21 Content analysis Qualitative Esmaeili (31) 2015 Understand the perspectives of policy- and decision-makers of Iran’s health system about the implementation of family medicine Ministry of Health and Medical Education/7 Semi-structured interviews, audio recorded, 50–75 minutes 27 Framework method Qualitative Iranian Health Insurance Organization/3 Medical universities and affiliated research centres/10 Iran Medical Council/2 Executive Directors in Pilot Provinces/5 Nejatzadegan (32) 2016 Challenges in the rural family doctor system Physicians enrolling in family physician programmes/8 Semi-structured interviews, audio recorded, 40–70 minutes, in-depth interview 21 Content analysis Qualitative Directors of physician programme/13 Shiyani (33) 2016 Challenges of family physician implementation Former Health Minister/2 Semi-structured interviews, audio recorded 23 Content analysis Qualitative Country Policymakers/11 Directors of physician programme/3 Directors of the Insurance Referral Center/2 Health experts/1 Deputy Health of Medical of University/2 Experts Family Physician Program/2 Sabet Sarvestani (34) 2017 Challenges of family physician Physicians enrolling in family physician programme/10 Semi-structured interviews, audio recorded, 60–90 minutes 17 Content analysis Qualitative Medical specialists/4 Pharmacists/2 Pathologist/1 First author (reference) Year Study focus/aim/perspective Number of type of participants Data collection method Number of participants Analysis method Study design Mehrolhassani (28) 2012 Challenges of implementing family physician Policy executives/10 Semi-structured focus group 10 Content analysis Qualitative Discussions, audio recorded Arab (29) 2013 Attitude of family physicians working in health and challenges Physicians/33 Semi-structured interviews, 45–60 minutes, focus group 33 Framework method Qualitative Dehnavieh (30) 2015 Implementation challenges of family physician 9 from Kerman University of Medical Science, 5 from health services insurance, 1 from the medical system and 6 experts (4 social physicians and 2 researchers in the field of family physician plan) Semi-structured interviews, audio recorded, 50 minutes, in-depth interview 21 Content analysis Qualitative Esmaeili (31) 2015 Understand the perspectives of policy- and decision-makers of Iran’s health system about the implementation of family medicine Ministry of Health and Medical Education/7 Semi-structured interviews, audio recorded, 50–75 minutes 27 Framework method Qualitative Iranian Health Insurance Organization/3 Medical universities and affiliated research centres/10 Iran Medical Council/2 Executive Directors in Pilot Provinces/5 Nejatzadegan (32) 2016 Challenges in the rural family doctor system Physicians enrolling in family physician programmes/8 Semi-structured interviews, audio recorded, 40–70 minutes, in-depth interview 21 Content analysis Qualitative Directors of physician programme/13 Shiyani (33) 2016 Challenges of family physician implementation Former Health Minister/2 Semi-structured interviews, audio recorded 23 Content analysis Qualitative Country Policymakers/11 Directors of physician programme/3 Directors of the Insurance Referral Center/2 Health experts/1 Deputy Health of Medical of University/2 Experts Family Physician Program/2 Sabet Sarvestani (34) 2017 Challenges of family physician Physicians enrolling in family physician programme/10 Semi-structured interviews, audio recorded, 60–90 minutes 17 Content analysis Qualitative Medical specialists/4 Pharmacists/2 Pathologist/1 View Large Quality assessment Table 2 illustrates the quality of studies conducted using CASP. Table 2. Critical Appraisal Skills Programme quality assessment of included studies First author/ reference Question 1 Question 2 Question 3 Question 4 Question 5 Question 6 Question 7 Question 8 Question 9 Question 10 Mehrolhassani (28) Yes Yes Yes No Yes Can’t tell Can’t tell No Yes Yes Arab (29) Yes Yes Can’t tell Yes Yes Can’t tell Can’t tell Can’t tell Yes Yes Dehnavieh (30) Yes Yes Yes Yes Yes Yes Can’t tell Can’t tell Yes Yes Esmaeili (31) Yes Yes Yes No Can’t tell Yes Yes Yes Yes Yes Nejatzadegan (32) Yes Yes Can’t tell Yes Yes Yes Yes Yes Yes Yes Shiyani (33) Yes Yes Can’t tell Yes Yes Can’t tell Can’t tell Can’t tell Yes Yes Sabet Sarvestani (34) Yes Yes Yes Yes Yes Yes Yes Can’t tell Yes Yes First author/ reference Question 1 Question 2 Question 3 Question 4 Question 5 Question 6 Question 7 Question 8 Question 9 Question 10 Mehrolhassani (28) Yes Yes Yes No Yes Can’t tell Can’t tell No Yes Yes Arab (29) Yes Yes Can’t tell Yes Yes Can’t tell Can’t tell Can’t tell Yes Yes Dehnavieh (30) Yes Yes Yes Yes Yes Yes Can’t tell Can’t tell Yes Yes Esmaeili (31) Yes Yes Yes No Can’t tell Yes Yes Yes Yes Yes Nejatzadegan (32) Yes Yes Can’t tell Yes Yes Yes Yes Yes Yes Yes Shiyani (33) Yes Yes Can’t tell Yes Yes Can’t tell Can’t tell Can’t tell Yes Yes Sabet Sarvestani (34) Yes Yes Yes Yes Yes Yes Yes Can’t tell Yes Yes View Large Table 2. Critical Appraisal Skills Programme quality assessment of included studies First author/ reference Question 1 Question 2 Question 3 Question 4 Question 5 Question 6 Question 7 Question 8 Question 9 Question 10 Mehrolhassani (28) Yes Yes Yes No Yes Can’t tell Can’t tell No Yes Yes Arab (29) Yes Yes Can’t tell Yes Yes Can’t tell Can’t tell Can’t tell Yes Yes Dehnavieh (30) Yes Yes Yes Yes Yes Yes Can’t tell Can’t tell Yes Yes Esmaeili (31) Yes Yes Yes No Can’t tell Yes Yes Yes Yes Yes Nejatzadegan (32) Yes Yes Can’t tell Yes Yes Yes Yes Yes Yes Yes Shiyani (33) Yes Yes Can’t tell Yes Yes Can’t tell Can’t tell Can’t tell Yes Yes Sabet Sarvestani (34) Yes Yes Yes Yes Yes Yes Yes Can’t tell Yes Yes First author/ reference Question 1 Question 2 Question 3 Question 4 Question 5 Question 6 Question 7 Question 8 Question 9 Question 10 Mehrolhassani (28) Yes Yes Yes No Yes Can’t tell Can’t tell No Yes Yes Arab (29) Yes Yes Can’t tell Yes Yes Can’t tell Can’t tell Can’t tell Yes Yes Dehnavieh (30) Yes Yes Yes Yes Yes Yes Can’t tell Can’t tell Yes Yes Esmaeili (31) Yes Yes Yes No Can’t tell Yes Yes Yes Yes Yes Nejatzadegan (32) Yes Yes Can’t tell Yes Yes Yes Yes Yes Yes Yes Shiyani (33) Yes Yes Can’t tell Yes Yes Can’t tell Can’t tell Can’t tell Yes Yes Sabet Sarvestani (34) Yes Yes Yes Yes Yes Yes Yes Can’t tell Yes Yes View Large Principal themes Initially, 133 codes were identified. In the second step, the codes were examined and the themes were merged based on their similarities and shared meaning. New codes were created through discussion. In the next and final step, eight themes emerged, namely, (i) financing; (ii) motivational factors; (iii) education; (iv) referral system; (v) performance evaluation; (vi) problems with health policy; (vii) health information system; and (vii) culture-building for proper policy implementation. For each of these main themes, major sub-themes were further identified. Theme 1. Financing Policy- and decision-makers provide health resources to service providers via different financing schemes and funds or incentives. One of the most important determinants for better health systems performance is health financing (35), which, according to WHO, includes revenue collection, pooling of resources and purchase of interventions (36). Delay in financial payments and insurance problems Following the implementation of FPP, financing has been provided through the public budget, which was funded by the Ministry of Health and Medical Education (MoHME) and the Ministry of Cooperatives, Labour, and Social Welfare (MoCLSW). Over time, financial problems have caused delays in payments to service providers (32). The wrong mechanism in determining the per capita payment mechanism To implement the per capita policy as preferred payment mechanism, physicians had to cover a certain number of patients and were paid according to the amount of services provided. The per capita scheme that was considered in this plan, however, did not fully take into account the services actually provided (28,32). Economic instability of the country Economic sanctions and international embargo policies imposed to Iran by European and American countries have caused many issues in the implementation of many health care programmes, seriously affecting the health sector and slowing down many plans of the MoHME (37). Economic stability, on the contrary, would make plan implementation easier (38). Inappropriate payment to specialists The salaries of the specialists were sometimes inadequate, with incentives for further collaborations having gradually diminished over time (30,32). Theme 2. Motivational factors The motivation of service providers in the health sector is the willingness to apply and try to reach the goals of the organization. Lack of motivation is one of the main barriers to providing effective health services (39,40). Lack of adequate facilities and support in less developed areas In developing areas, many family physicians have faced the lack of adequate health facilities, which has made them less willing to attend those settings, privileging more developed regions (30,32). Volume of health care services provided and long working hours In many provinces of Iran, there is a shortage of health workers, including physicians, nurses and other workforces. The ratio of physician to population is inadequate (28), also considering the workload and responsibilities of the family physician (32). The working hours of FPP are from morning until evening, due to the high volume of visits (30). Bureaucracy has dramatically increased the workload (29). Low salary Compared with other jobs, the salaries of staff providing family physician services are low, and this also has a negative impact on motivation to attend the programme (32). Uncertain employment status for service provider staff People engaged in the implementation of FPP need a stable job situation, and the absence of good economic conditions has caused serious concerns and worries among them (28,32). Theme 3. Education Inadequate skills and training for service providers and lack of retraining programmes The inadequacy of training for the expected duties of family physicians, the lack of a community-based vision in the educational system and the lack of involvement of the members of the health team were among the challenges posed by the family physician’s education system (28). Studies showed that there were insufficient skills and training levels in doctors to better implement this plan (30,33). Service providers, after entering FPP, faced many problems with the implementation of programmes, thus requiring training and education (28). Theme 4. Referral system An effective referral system prevents unnecessary visits to more specialized levels as well as the waste of material and human resources. As such, it is a good tool for controlling the health care costs and increasing the standardization of clinical practices between general practitioners and specialists (31). Theme 5. Performance evaluation Following the implementation of FPP, to assess the performance of service providers, the two ministries of health and welfare, based on an ad hoc designed checklist, evaluated the performance and made the payment. However, there was an imbalance between the performance controller and the health team (32). Theme 6. Problems with health policy Failure to execute a pilot programme To better implement a policy, a pilot programme can first be implemented in order to identify its weaknesses and strengths. Pilot implementation of a project prevents possible multiple problems arising from the project itself (32). However, FPP was quickly implemented, and many of the facilities were not available to be tested and assessed. Lack of knowledge from service providers caused many problems for the implementation of the plan (30). Furthermore, the lack of justification of the political and executive authorities or the insufficient information provided was another issue (28). Inappropriate cooperation between the two ministries of health and welfare The implementation of FPP was the responsibility of two ministries of health and welfare. The lack of coordination between the two institutions has caused confusion and problems both for providers and recipients of services and for the insurance system (33). There were problems with the implementation of the Memorandum of Understanding due to inconsistencies between the two ministries (28). Centralized planning Decision-making process was top-down and centralized rather than collaborative and participatory, thus leading to debates and controversies (33). Not paying attention to insurance problems Insurance companies have a valuable role in the development of health services (30), even though many individuals were not covered by any insurance programme (28). Not using the potential of the private sector FPP has reduced private sector income, without leading to a proper private sector cooperation (33), also due to financial problems and delays in payments. The private sector in order to provide health care services needs to get the right funds at the right time and, therefore, has encountered problems in order to provide services (32). Theme 7. Health information system Lack of electronic health database of individuals The full implementation of an electronic health care system has faced delays due to missing or inaccurate information, timely inaccessibility of information and the inability to access patients’ information in different geographical areas, considering the high volume of visits and referrals (28). No suitable infrastructure for the development of the health information system was available, which caused further problems in implementing this plan (30). It took a lot of time, indeed, to digitalize all the patients’ data and records (32). With the advent of information and communication technologies (ICTs), doctors should properly and effectively exploit electronic records (29). Theme 8. Culture-building for proper policy implementation Low acquaintance and lack of cooperation with family physicians The implementation of FPP requires inter-sector collaboration and people’s participation. Culture-building is, therefore, essential. Service recipients must receive appropriate training in order to implement policies more effectively (28). Health care providers should share with communities information about health projects (32). Lack of approach to general physician services Low trust in the services provided by GPs is one of the barriers to a full effective implementation of FPP (28), in which people properly receive their basic services and, then, are introduced to the specialists (34). Discussion FPP represent a valuable asset of PHC-based programmes (41). The World Organization of Family Doctors (WONCA) recommends that FPP makes use mainly of primary health services (9,42). The use of scientific evidence can enhance and strengthen the health systems and also improve the health of the community and reduce health inequalities (43). The present study was conducted to dissect the major challenges faced by FPP in Iran using published qualitative studies. Eight themes were identified. Financial problems represent a major barrier to the full implementation of FPP in Iran (44,45). FPP requires good funding and paying for performance is expected to dramatically improve its performance (46). The delays in payments by the government and the lack of proper cooperation between the ministries, as well as the wrong mechanisms of per capita financing schemes differing among the Iranian regions, have caused financial issues, leading to providers’ dissatisfaction or negatively impacting on physicians’ performance (47). It seems that, in order to increase the efficiency of FPP, new financial models are needed in order to reimburse physicians according to their performance, coverage and activities. This could result in cost saving and better use of financial resources (48). Furthermore, since 1979, Iran has been subject to economic sanctions, experiencing difficulties in properly allocating health care financial resources (49) and suffering from a fragile economic structure (50). Another theme is given by physician motivation (7,29,51), with most doctors and health care workers being dissatisfied for the heavy workload and the low salary (21,42,47). Furthermore, in Iran, the difference in facilities for physicians in developed and less developed regions is enormous. Despite the shortage of physicians, doctors who are enrolled do not have a permanent position (52). Financial incentives should play a major role (47,53–55). Moreover, there is a lack of ad hoc training (56) and of ongoing educational programmes (57). Solving these educational needs could increase the effectiveness and efficiency of FPP-related activities (58). A good effective referral system is another important dimension of FPP. In PHC, the distribution of health care services should be consistent with community health needs. The referral system enables a fair use of health facilities based on the needs and priorities of the patients (59). Recently, in Iran, the referral system has become a mandatory law (60). Unfortunately, there are still many problems with creating a proper referral system (17). Studies conducted to review the referral system in FPP indicate that serious reforms are urgently needed (57,61). Performance evaluation, in addition to providing information feedback, outlines the expectations that decision- and policy-makers have about implementing health policies (62). Performance appraisal enables the organizations to modify and dynamically change their paths according to variable conditions (63). To evaluate the performance of services provided by FPP, checklists based on performance indicators have been elaborated, but, after their implementation, a policy of valid checklists has not been established between the two Ministries and this has led to the discontent of service providers in many cases. Furthermore, the checklist did not include some indicators that, according to some experts, should be considered (64). A policy, before being implemented, should be pilot tested, in such a way that decision- and policy-makers can have a good understanding of potential difficulties and challenges (65). For example, before the implementation of FPP, it would have been better to integrate Iran’s insurance to make a major contribution to a better economic-financial sustainability (56). A study conducted to examine the factors needed for the full implementation of FPP examined six aspects, namely, communication infrastructure, stakeholders and actors, structural infrastructure, technical and human resources, legal and civic education (66). Another important point is that the Iranian institutions should favour inter-sector and intra-sector cooperation in order to reduce the problems faced by FPP (67). The private sector can play an effective role in improving FPP performance, since it has all the facilities and resources FPP needs, which, on the contrary, are poorly exploited (68,69). Furthermore, health records are a major source of health-related information, aimed at supporting continuity of care, informing and guiding hospitalization process, providing training and facilitating communication between doctors and patients. The electronic registration of all health services provided is one of the important duties of FPP (70). Unfortunately, the health electronic infrastructure in Iran has not yet been completed, and many people do not yet have an electronic health record (71). As such, there is a need for the completion of the health information system in order to improve the health of the people. Finally, geographical and cultural diversity in Iran can represent another challenge. A lack of coordination between people and service providers leads to a lack of proper implementation of health care policies (72). In order to empower the plan and ensure optimal allocation of resources, participation of people and other sectors is essential (73). The favourable cooperation of local institutions requires knowledge and recognition of the goals and criteria set (74). Building-culture is, therefore, fundamental. It is necessary to educate people about health policy through mass media such as television, radio and local newspapers, as well as through new ICTs such as social networks and social media (7,53,75). If we compare our findings with the challenges encountered by the implementation of FPPs in other countries, we can see that, apart from some difficulties typical of the local context of Iran (such as international embargo sanctions to Iran), these obstacles are well comparable (76). According to some surveys, a relevant number of family practitioners suffer, indeed, from severe stress and health-related problems, job discontent and dissatisfaction due to heavy workload, bureaucracy, patients’ requests, insufficient financial compensation and lack of time leading to imbalance in personal and professional life (55,76–85). What other countries can learn from the Iranian experience as they seek to develop/improve PHC in their countries is that, even in times of economic-financial constraints such as the Iranian embargo or the 2007–2008 global financial crisis, health still remains a priority and can be ensured by means of a resilient, solid health care network. What Iran can learn from other experiences worldwide is that a more decentralized infrastructure would be more effective in providing health services (86). Family practitioners represent an overarching element of PHC, and health decision- and policy-makers should make efforts in order to address their challenges, in order to achieve higher health levels. Strengths and limitations of this study Regarding the strengths of this investigation, to the best of our knowledge, this study represents the first systematic review and meta-synthesis of qualitative researches carried out in a rigorous way following standardized protocols and guidelines and focusing on the challenges and barriers of FPP in Iran in order to help and assist health care decision- and policy-makers. Concerning limitations, only seven peer-reviewed published studies were included: these may suffer from a number of limitations in terms of quality and methodology, which calls for caution in generalizing the findings of this study. The participants were mostly physicians, policy-makers and decision-makers implementing this policy. Of the service recipients, the most important customers of this policy were not used as participants. Furthermore, existing cultural differences between participants could have influenced the findings of studies. Conclusion Meta-synthesis studies can be a good way to better understand viewpoints and recommendations on a given health policy topic, being a very valuable guide for health policy- and decision-makers. FPP has had positive effects on health in Iran. There are, however, challenges in fully implementing its policy, which makes it difficult to achieve its objectives. Decision- and policy-makers in Iran should address these issues. Furthermore, based on the above-mentioned shortcomings, it would be very useful to conduct further studies collecting stakeholders’ views on FPP. Declaration Funding: none. Ethical approval: none. Conflict of interest: none. References 1. Jannati A , Maleki M , Gholizade M , Narimani M , Vakeli S . Assessing the strengths and weaknesses of family physician program . Knowl Health 2010 ; 4 : 39 – 44 . 2. Green A , Collins C , Stefanini A , et al. 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Health Scope 2017 ; 6 : e34459 . © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - The challenges of the family physician policy in Iran: a systematic review and meta-synthesis of qualitative researches
JF - Family Practice
DO - 10.1093/fampra/cmy035
DA - 2018-12-12
UR - https://www.deepdyve.com/lp/oxford-university-press/the-challenges-of-the-family-physician-policy-in-iran-a-systematic-kPLyaIk7dd
SP - 652
VL - 35
IS - 6
DP - DeepDyve
ER -