The challenges of the family physician policy in Iran: a systematic review and meta-synthesis of qualitative researches

The challenges of the family physician policy in Iran: a systematic review and meta-synthesis of... 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. The role of strategic health planning processes in the development of health care reform policies: a comparative study of Eritrea, Mozambique and Zimbabwe . Int J Health Plann Manage 2007 ; 22 : 113 – 31 . Google Scholar CrossRef Search ADS PubMed 3. Veillard JH , Brown AD , Barış E , Permanand G , Klazinga NS . Health system stewardship of National Health Ministries in the WHO European region: concepts, functions and assessment framework . Health Policy 2011 ; 103 : 191 – 9 . Google Scholar CrossRef Search ADS PubMed 4. Evans DB , Hsu J , Boerma T . Universal health coverage and universal access . Bull World Health Organ 2013 ; 91 : 546 – 546A . Google Scholar CrossRef Search ADS PubMed 5. Ghebreyesus TA . All roads lead to universal health coverage . Lancet Glob Health 2017 ; 5 : e839 – 40 . Google Scholar CrossRef Search ADS PubMed 6. Rahman SM , Angeline RP , David KV , Christopher P . Role of family medicine education in India’s step toward universal health coverage . J Fam Med Prim Care 2014 ; 3 : 180 – 2 . Google Scholar CrossRef Search ADS 7. Majdzadeh R . Family physician implementation and preventive medicine; opportunities and challenges . Int J Prev Med 2012 ; 3 : 665 – 9 . Google Scholar PubMed 8. 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 : 122 . Google Scholar CrossRef Search ADS PubMed 9. De Maeseneer J , Flinkenflögel M . Primary health care in Africa: do family physicians fit in ? Br J Gen Pract 2010 ; 60 : 286 – 92 . Google Scholar CrossRef Search ADS PubMed 10. van der Voort CT , van Kasteren G , Chege P , Dinant GJ . What challenges hamper Kenyan family physicians in pursuing their family medicine mandate? A qualitative study among family physicians and their colleagues . BMC Fam Pract 2012 ; 13 : 32 . Google Scholar CrossRef Search ADS PubMed 11. Kringos DS , Boerma WG , Bourgueil Y , et al. The European primary care monitor: structure, process and outcome indicators . BMC Fam Pract 2010 ; 11 : 81 . Google Scholar CrossRef Search ADS PubMed 12. Masic I , Hadziahmetovic M , Donev D , et al. Public health aspects of the family medicine concepts in South Eastern Europe . Mater Sociomed 2014 ; 26 : 277 – 86 . Google Scholar CrossRef Search ADS PubMed 13. Oleszczyk M , Svab I , Seifert B , Krztoń-Królewiecka A , Windak A . Family medicine in post-communist Europe needs a boost. Exploring the position of family medicine in healthcare systems of Central and Eastern Europe and Russia . BMC Fam Pract 2012 ; 13 : 15 . Google Scholar CrossRef Search ADS PubMed 14. Abyad A , Al-Baho AK , Unluoglu I , Tarawneh M , Al Hilfy TK . Development of family medicine in the Middle East . Fam Med 2007 ; 39 : 736 – 41 . Google Scholar PubMed 15. Shadpour K . Primary health care networks in the Islamic Republic of Iran . East Mediterr Health J 2000 ; 6 : 822 – 5 . Google Scholar PubMed 16. Keshvari M , Mohammadi E , Farajzadegan Z , Zargham-Boroujeni A . Experience of Behvarzes (Iranian primary healthcare providers) from giving primary health services in health houses . J Educ Health Promot 2016 ; 5 : 7 . Google Scholar CrossRef Search ADS PubMed 17. Takian A , Rashidian A , Kabir MJ . Expediency and coincidence in re-engineering a health system: an interpretive approach to formation of family medicine in Iran . Health Policy Plan 2011 ; 26 : 163 – 73 . Google Scholar CrossRef Search ADS PubMed 18. Rashidian A , Joudaki H , Khodayari-Moez E , Omranikhoo H , Geraili B , Arab M . The impact of rural health system reform on hospitalization rates in the Islamic Republic of Iran: an interrupted time series . Bull World Health Organ 2013 ; 91 : 942 – 9 . Google Scholar CrossRef Search ADS PubMed 19. Naderimagham S , Jamshidi H , Khajavi A , et al. Impact of rural family physician program on child mortality rates in Iran: a time-series study . Popul Health Metr 2017 ; 15 : 21 . Google Scholar CrossRef Search ADS PubMed 20. 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 : 551 – 9 . Google Scholar CrossRef Search ADS PubMed 21. Suki NM , Lian JC , Suki NM . Do patients’ perceptions exceed their expectations in private healthcare settings ? Int J Health Care Qual Assur 2011 ; 24 : 42 – 56 . Google Scholar CrossRef Search ADS PubMed 22. Walsh D , Downe S . Meta-synthesis method for qualitative research: a literature review . J Adv Nurs 2005 ; 50 : 204 – 11 . Google Scholar CrossRef Search ADS PubMed 23. Tong A , Flemming K , McInnes E , Oliver S , Craig J . Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ . BMC Med Res Methodol 2012 ; 12 : 181 . Google Scholar CrossRef Search ADS PubMed 24. Mohammed MA , Moles RJ , Chen TF . Meta-synthesis of qualitative research: the challenges and opportunities . Int J Clin Pharm 2016 ; 38 : 695 – 704 . Google Scholar PubMed 25. Moher D , Shamseer L , Clarke M , et al. ; PRISMA-P Group . Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement . Syst Rev 2015 ; 4 : 1 . Google Scholar CrossRef Search ADS PubMed 26. Critical Appraisal Skills Programme (CASP) . CASP Qualitative Research Checklist . 2017 . http://www.casp-uk.net/casp-tools-checklists (accessed on 26 April 2018). 27. Noblit GW , Hare RD. Meta-Ethnography: Synthesizing Qualitative Studies . London, UK : Sage , 1988 . 28. Mehrolhassani MH , Jafari Sirizi M , Poorhoseini SS , Yazdi Feyzabadi V . The challenges of implementing family physician and rural insurance policies in Kerman province, Iran: a qualitative study . J Health Dev 2012 ; 1 : 193 – 206 . 29. Arab M , Shafiee M , Iree M , et al. Surveying the attitude of family physicians working in health centers of Tehran University of Medical Sciences towards their profession using a qualitative approach . J Hosp 2013 ; 12 : 19 – 28 . 30. 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 . Google Scholar PubMed 31. Esmaeili R , Hadian M , Rashidian A , Shariati M , Ghaderi H . Family medicine in Iran: facing the health system challenges . Glob J Health Sci 2014 ; 7 : 260 – 6 . Google Scholar CrossRef Search ADS PubMed 32. Nejatzadegan Z , Ebrahimipour H , Hooshmand E , et al. Challenges in the rural family doctor system in Iran in 2013–14: a qualitative approach . Fam Pract 2016 ; 33 : 421 – 5 . Google Scholar CrossRef Search ADS PubMed 33. Shiyani M , Rashidian A , Mohammadi A . A study of the challenges of family physician implementation in Iran health system . Hakim Health Sys Res 2016 ; 18 : 264 – 74 . 34. Sabet Sarvestani R , Najafi Kalyani M , Alizadeh F , et al. Challenges of family physician program in urban areas: a qualitative research . Arch Iran Med 2017 ; 20 : 446 – 51 . Google Scholar PubMed 35. Fryatt RJ , Bhuwanee K . Financing health systems to achieve the health sustainable development goals . Lancet Glob Health 2017 ; 5 : e841 – 2 . Google Scholar CrossRef Search ADS PubMed 36. World Health Report . The World Health Report 2000—Health Systems: Improving Performance . 2000 . http://www.who.int/whr/2000/en/ (accessed on 26 April 2018). 37. Vogenberg FR , Cutts S . Economic instability and its impact on decision making in health care . PT 2009 ; 34 : 24 – 5 . 38. Hopkins S . Economic stability and health status: evidence from East Asia before and after the 1990s economic crisis . Health Policy 2006 ; 75 : 347 – 57 . Google Scholar CrossRef Search ADS PubMed 39. Willis-Shattuck M , Bidwell P , Thomas S , et al. Motivation and retention of health workers in developing countries: a systematic review . BMC Health Serv Res 2008 ; 8 : 247 . Google Scholar CrossRef Search ADS PubMed 40. Dolea C , Stormont L , Braichet JM . Evaluated strategies to increase attraction and retention of health workers in remote and rural areas . Bull World Health Organ 2010 ; 88 : 379 – 85 . Google Scholar CrossRef Search ADS PubMed 41. van Weel C . Primary health care and family medicine at the core of health care: challenges and priorities in how to further strengthen their potential . Front Med (Lausanne) 2014 ; 1 : 37 . Google Scholar PubMed 42. Strasser R . Rural health around the world: challenges and solutions . Fam Pract 2003 ; 20 : 457 – 63 . Google Scholar CrossRef Search ADS PubMed 43. Hanney SR , Gonzalez-Block MA , Buxton MJ , Kogan M . The utilisation of health research in policy-making: concepts, examples and methods of assessment . Health Res Policy Syst 2003 ; 1 : 2 . Google Scholar CrossRef Search ADS PubMed 44. Stenberg K , Hanssen O , Edejer TT , et al. Financing transformative health systems towards achievement of the health sustainable development goals: a model for projected resource needs in 67 low-income and middle-income countries . Lancet Glob Health 2017 ; 5 : e875 – 87 . Google Scholar CrossRef Search ADS PubMed 45. Kutzin J . Health financing for universal coverage and health system performance: concepts and implications for policy . Bull World Health Organ 2013 ; 91 : 602 – 11 . Google Scholar CrossRef Search ADS PubMed 46. Eijkenaar F . Key issues in the design of pay for performance programs . Eur J Health Econ 2013 ; 14 : 117 – 31 . Google Scholar CrossRef Search ADS PubMed 47. Duffy RD , Richard GV . Physician job satisfaction across six major specialties . J Vocat Behav 2006 ; 68 : 548 – 59 . Google Scholar CrossRef Search ADS 48. Spann SJ . Report on financing the new model of family medicine . Ann Fam Med 2004 ; 2 ( suppl 3 ): s1 – 21 . Google Scholar CrossRef Search ADS PubMed 49. Massoumi RL , Koduri S . Adverse effects of political sanctions on the health care system in Iran . J Glob Health 2015 ; 5 : 020302 . Google Scholar CrossRef Search ADS PubMed 50. Ng KH , Agius M , Zaman R . The global economic crisis: effects on mental health and what can be done . J R Soc Med 2013 ; 106 : 211 – 4 . Google Scholar CrossRef Search ADS PubMed 51. Lankarani KB , Alavian SM , Haghdoost AA . Family physicians in Iran: success despite challenges . Lancet 2010 ; 376 : 1540 – 1 . Google Scholar CrossRef Search ADS PubMed 52. Dieleman M , Cuong PV , Anh LV , Martineau T . Identifying factors for job motivation of rural health workers in North Vietnam . Hum Resour Health 2003 ; 1 : 10 . Google Scholar CrossRef Search ADS PubMed 53. Miedema B , Hamilton R , Fortin P , Easley J , Tatemichi S . The challenges and rewards of rural family practice in New Brunswick, Canada: lessons for retention . Rural Remote Health 2009 ; 9 : 1141 . Google Scholar PubMed 54. Rockers PC , Jaskiewicz W , Wurts L , et al. Preferences for working in rural clinics among trainee health professionals in Uganda: a discrete choice experiment . BMC Health Serv Res 2012 ; 12 : 212 . Google Scholar CrossRef Search ADS PubMed 55. Simoens S , Scott A , Sibbald B . Job satisfaction, work-related stress and intentions to quit of Scottish GPS . Scott Med J 2002 ; 47 : 80 – 6 . Google Scholar CrossRef Search ADS PubMed 56. Dehnavieh R , Rashidian A , Maleki M . Challenges of determining basic health insurance package in Iran . Payesh J 2011 ; 10 : 273 – 83 . 57. Dehnavieh R , Movahed E , Rahimi H , et al. Evaluation of the referral system in Iran’s rural family physician program; a study of Jiroft University of Medical Sciences . Electron Physician 2017 ; 9 : 4225 – 30 . Google Scholar CrossRef Search ADS PubMed 58. Norris TE , Coombs JB , Carline J . An educational needs assessment of rural family physicians . J Am Board Fam Pract 1996 ; 9 : 86 – 93 . Google Scholar PubMed 59. Ferdosi M , Vatankhah S , Khalesi N , Ayoobian A . Designing a referral system management model for direct treatment in social security organization . J Mil Med 2012 ; 14 : 129 – 35 . 60. Vosoogh Moghaddam A , Damari B , Alikhani S , et al. Health in the 5th 5-years development plan of Iran: main challenges, general policies and strategies . Iran J Public Health 2013 ; 42 ( suppl. 1 ): 42 – 9 . Google Scholar PubMed 61. Golalizadeh E , Moosazadeh M , Amiresmaili M , Ahangar N . Challenges related to second level of the referral system in family medicine plan: a qualitative research . J Med Council Iran 2012 ; 29 : 309 – 21 . 62. Kolozsvári LR , Rurik I . Evaluation of the quality of performance of general practitioners: what is the problem with primary care quality indicators in Hungary ? Orv Hetil 2016 ; 157 : 328 – 35 . Google Scholar CrossRef Search ADS PubMed 63. Rosen MA , Pronovost PJ . Advancing the use of checklists for evaluating performance in health care . Acad Med 2014 ; 89 : 963 – 5 . Google Scholar CrossRef Search ADS PubMed 64. Yazdi Feyzabadi V , Khosravi S , Amiresmaili M . Performance evaluation of rural family physician plan: a case of Kerman University of Medical Sciences . TB 2014 ; 12 : 48 – 59 . 65. Glanz K , Barbara K , Rimer K , Viswanat H. Health Behavior and Health Education: Theory, Research, and Practice , 4th edn . San Francisco, CA : Jonh Wily & Sons Inc ., 2008 . 66. Doshmangir L , Doshmangir P , Abbasi M , Rashidian A . Infrastructures for implementation of urban family medicine in Iran: infrastructures for implementation of urban family medicine in Iran . Hakim Health Sys Res 2015 ; 18 : 1 – 13 . 67. Moshiri E , Takian A , Rashidian A , Kabir MJ . Expediency and coincidence in the formation of family physician and universal rural health insurance in Iran . Hakim Health Sys Res . 2012 ; 15 : 288 . 68. Arya N , Gibson C , Ponka D , et al. Family medicine around the world: overview by region: The Besrour Papers: a series on the state of family medicine in the world . Can Fam Phys 2017 ; 63 : 436 – 41 . 69. Aligol M , Mohammadbeigi A . Assessment of private sector physicians’ willingness to participate in family physician program using the diffusion of innovation model, Qom, 2012, Iran . Qom Univ Med Sci J 2014 ; 8 : 27 – 34 . 70. Kabir MJ , Jafari N , Nahimi Tabihi M , et al. Health record and provided services recording among centers implementing rural family physician and insurance program in Northern provinces of Iran . J Hosp 2015 ; 14 : 61 – 9 . 71. Yazdi-Feyzabadi V , Emami M , Mehrolhassani MH . Health information system in primary health care: the challenges and barriers from local providers’ perspective of an area in Iran . Int J Prev Med 2015 ; 6 : 57 . Google Scholar PubMed 72. Jafarzadeh S , Mobasheri F , Bahramali E . Caregivers awareness about the rules of family physician program in Fasa in the year 2014 . J Fasa Univ Med Sci 2016 ; 6 : 326 – 33 . 73. Etemadi F , Malekafzali Ardakani H , Dejman M . Evaluation of public participation and intersectoral collaboration in family physician program in rural areas of Iran . Hakim Health Sys Res 2015 ; 18 : 182 – 93 . 74. Kabir M , Jafari N , Naeimi Tabiei M , et al. Rate familiarity of the members of local organizations in the Northern provinces of Iran about the family physician programme and rural insurance . TB 2015 ; 14 : 12 – 24 . 75. Cole AM , Chen FM , Ford PA , Phillips WR , Stevens NG . Rewards and challenges of community health center practice . J Prim Care Community Health 2014 ; 5 : 148 – 51 . Google Scholar CrossRef Search ADS PubMed 76. Manca DP , Varnhagen S , Brett-MacLean P , et al. Rewards and challenges of family practice: web-based survey using the Delphi method . Can Fam Phys 2007 ; 53 : 278 – 86 . 77. Appleton K , House A , Dowell A . A survey of job satisfaction, sources of stress and psychological symptoms among general practitioners in Leeds . Br J Gen Pract 1998 ; 48 : 1059 – 63 . Google Scholar PubMed 78. Cooper CL , Rout U , Faragher B . Mental health, job satisfaction, and job stress among general practitioners . BMJ 1989 ; 298 : 366 – 70 . Google Scholar CrossRef Search ADS PubMed 79. Dowell AC , Hamilton S , McLeod DK . Job satisfaction, psychological morbidity and job stress among New Zealand general practitioners . N Z Med J 2000 ; 113 : 269 – 72 . Google Scholar PubMed 80. Landon BE , Aseltine R Jr , Shaul JA , et al. Evolving dissatisfaction among primary care physicians . Am J Manag Care 2002 ; 8 : 890 – 901 . Google Scholar PubMed 81. McGlone SJ , Chenoweth IG . Job demands and control as predictors of occupational satisfaction in general practice . Med J Aust 2001 ; 175 : 88 – 91 . Google Scholar PubMed 82. Post DM . Values, stress, and coping among practicing family physicians . Arch Fam Med 1997 ; 6 : 252 – 5 . Google Scholar CrossRef Search ADS PubMed 83. Schattner PL , Coman GJ . The stress of metropolitan general practice . Med J Aust 1998 ; 169 : 133 – 7 . Google Scholar PubMed 84. Spurgeon P , Barwell F , Maxwell R . Types of work stress and implications for the role of general practitioners . Health Serv Manage Res 1995 ; 8 : 186 – 97 . Google Scholar CrossRef Search ADS PubMed 85. Sutherland VJ , Cooper CL . Job stress, satisfaction, and mental health among general practitioners before and after introduction of new contract . BMJ 1992 ; 304 : 1545 – 8 . Google Scholar CrossRef Search ADS PubMed 86. Khangah HA , Jannati A , Imani A , et al. Comparing the health care system of Iran with various countries . 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/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

The challenges of the family physician policy in Iran: a systematic review and meta-synthesis of qualitative researches

Loading next page...
 
/lp/ou_press/the-challenges-of-the-family-physician-policy-in-iran-a-systematic-kPLyaIk7dd
Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
ISSN
0263-2136
eISSN
1460-2229
D.O.I.
10.1093/fampra/cmy035
Publisher site
See Article on Publisher Site

Abstract

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. The role of strategic health planning processes in the development of health care reform policies: a comparative study of Eritrea, Mozambique and Zimbabwe . Int J Health Plann Manage 2007 ; 22 : 113 – 31 . Google Scholar CrossRef Search ADS PubMed 3. Veillard JH , Brown AD , Barış E , Permanand G , Klazinga NS . Health system stewardship of National Health Ministries in the WHO European region: concepts, functions and assessment framework . Health Policy 2011 ; 103 : 191 – 9 . Google Scholar CrossRef Search ADS PubMed 4. Evans DB , Hsu J , Boerma T . Universal health coverage and universal access . Bull World Health Organ 2013 ; 91 : 546 – 546A . Google Scholar CrossRef Search ADS PubMed 5. Ghebreyesus TA . All roads lead to universal health coverage . Lancet Glob Health 2017 ; 5 : e839 – 40 . Google Scholar CrossRef Search ADS PubMed 6. Rahman SM , Angeline RP , David KV , Christopher P . Role of family medicine education in India’s step toward universal health coverage . J Fam Med Prim Care 2014 ; 3 : 180 – 2 . Google Scholar CrossRef Search ADS 7. Majdzadeh R . Family physician implementation and preventive medicine; opportunities and challenges . Int J Prev Med 2012 ; 3 : 665 – 9 . Google Scholar PubMed 8. 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 : 122 . Google Scholar CrossRef Search ADS PubMed 9. De Maeseneer J , Flinkenflögel M . Primary health care in Africa: do family physicians fit in ? Br J Gen Pract 2010 ; 60 : 286 – 92 . Google Scholar CrossRef Search ADS PubMed 10. van der Voort CT , van Kasteren G , Chege P , Dinant GJ . What challenges hamper Kenyan family physicians in pursuing their family medicine mandate? A qualitative study among family physicians and their colleagues . BMC Fam Pract 2012 ; 13 : 32 . Google Scholar CrossRef Search ADS PubMed 11. Kringos DS , Boerma WG , Bourgueil Y , et al. The European primary care monitor: structure, process and outcome indicators . BMC Fam Pract 2010 ; 11 : 81 . Google Scholar CrossRef Search ADS PubMed 12. Masic I , Hadziahmetovic M , Donev D , et al. Public health aspects of the family medicine concepts in South Eastern Europe . Mater Sociomed 2014 ; 26 : 277 – 86 . Google Scholar CrossRef Search ADS PubMed 13. Oleszczyk M , Svab I , Seifert B , Krztoń-Królewiecka A , Windak A . Family medicine in post-communist Europe needs a boost. Exploring the position of family medicine in healthcare systems of Central and Eastern Europe and Russia . BMC Fam Pract 2012 ; 13 : 15 . Google Scholar CrossRef Search ADS PubMed 14. Abyad A , Al-Baho AK , Unluoglu I , Tarawneh M , Al Hilfy TK . Development of family medicine in the Middle East . Fam Med 2007 ; 39 : 736 – 41 . Google Scholar PubMed 15. Shadpour K . Primary health care networks in the Islamic Republic of Iran . East Mediterr Health J 2000 ; 6 : 822 – 5 . Google Scholar PubMed 16. Keshvari M , Mohammadi E , Farajzadegan Z , Zargham-Boroujeni A . Experience of Behvarzes (Iranian primary healthcare providers) from giving primary health services in health houses . J Educ Health Promot 2016 ; 5 : 7 . Google Scholar CrossRef Search ADS PubMed 17. Takian A , Rashidian A , Kabir MJ . Expediency and coincidence in re-engineering a health system: an interpretive approach to formation of family medicine in Iran . Health Policy Plan 2011 ; 26 : 163 – 73 . Google Scholar CrossRef Search ADS PubMed 18. Rashidian A , Joudaki H , Khodayari-Moez E , Omranikhoo H , Geraili B , Arab M . The impact of rural health system reform on hospitalization rates in the Islamic Republic of Iran: an interrupted time series . Bull World Health Organ 2013 ; 91 : 942 – 9 . Google Scholar CrossRef Search ADS PubMed 19. Naderimagham S , Jamshidi H , Khajavi A , et al. Impact of rural family physician program on child mortality rates in Iran: a time-series study . Popul Health Metr 2017 ; 15 : 21 . Google Scholar CrossRef Search ADS PubMed 20. 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 : 551 – 9 . Google Scholar CrossRef Search ADS PubMed 21. Suki NM , Lian JC , Suki NM . Do patients’ perceptions exceed their expectations in private healthcare settings ? Int J Health Care Qual Assur 2011 ; 24 : 42 – 56 . Google Scholar CrossRef Search ADS PubMed 22. Walsh D , Downe S . Meta-synthesis method for qualitative research: a literature review . J Adv Nurs 2005 ; 50 : 204 – 11 . Google Scholar CrossRef Search ADS PubMed 23. Tong A , Flemming K , McInnes E , Oliver S , Craig J . Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ . BMC Med Res Methodol 2012 ; 12 : 181 . Google Scholar CrossRef Search ADS PubMed 24. Mohammed MA , Moles RJ , Chen TF . Meta-synthesis of qualitative research: the challenges and opportunities . Int J Clin Pharm 2016 ; 38 : 695 – 704 . Google Scholar PubMed 25. Moher D , Shamseer L , Clarke M , et al. ; PRISMA-P Group . Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement . Syst Rev 2015 ; 4 : 1 . Google Scholar CrossRef Search ADS PubMed 26. Critical Appraisal Skills Programme (CASP) . CASP Qualitative Research Checklist . 2017 . http://www.casp-uk.net/casp-tools-checklists (accessed on 26 April 2018). 27. Noblit GW , Hare RD. Meta-Ethnography: Synthesizing Qualitative Studies . London, UK : Sage , 1988 . 28. Mehrolhassani MH , Jafari Sirizi M , Poorhoseini SS , Yazdi Feyzabadi V . The challenges of implementing family physician and rural insurance policies in Kerman province, Iran: a qualitative study . J Health Dev 2012 ; 1 : 193 – 206 . 29. Arab M , Shafiee M , Iree M , et al. Surveying the attitude of family physicians working in health centers of Tehran University of Medical Sciences towards their profession using a qualitative approach . J Hosp 2013 ; 12 : 19 – 28 . 30. 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 . Google Scholar PubMed 31. Esmaeili R , Hadian M , Rashidian A , Shariati M , Ghaderi H . Family medicine in Iran: facing the health system challenges . Glob J Health Sci 2014 ; 7 : 260 – 6 . Google Scholar CrossRef Search ADS PubMed 32. Nejatzadegan Z , Ebrahimipour H , Hooshmand E , et al. Challenges in the rural family doctor system in Iran in 2013–14: a qualitative approach . Fam Pract 2016 ; 33 : 421 – 5 . Google Scholar CrossRef Search ADS PubMed 33. Shiyani M , Rashidian A , Mohammadi A . A study of the challenges of family physician implementation in Iran health system . Hakim Health Sys Res 2016 ; 18 : 264 – 74 . 34. Sabet Sarvestani R , Najafi Kalyani M , Alizadeh F , et al. Challenges of family physician program in urban areas: a qualitative research . Arch Iran Med 2017 ; 20 : 446 – 51 . Google Scholar PubMed 35. Fryatt RJ , Bhuwanee K . Financing health systems to achieve the health sustainable development goals . Lancet Glob Health 2017 ; 5 : e841 – 2 . Google Scholar CrossRef Search ADS PubMed 36. World Health Report . The World Health Report 2000—Health Systems: Improving Performance . 2000 . http://www.who.int/whr/2000/en/ (accessed on 26 April 2018). 37. Vogenberg FR , Cutts S . Economic instability and its impact on decision making in health care . PT 2009 ; 34 : 24 – 5 . 38. Hopkins S . Economic stability and health status: evidence from East Asia before and after the 1990s economic crisis . Health Policy 2006 ; 75 : 347 – 57 . Google Scholar CrossRef Search ADS PubMed 39. Willis-Shattuck M , Bidwell P , Thomas S , et al. Motivation and retention of health workers in developing countries: a systematic review . BMC Health Serv Res 2008 ; 8 : 247 . Google Scholar CrossRef Search ADS PubMed 40. Dolea C , Stormont L , Braichet JM . Evaluated strategies to increase attraction and retention of health workers in remote and rural areas . Bull World Health Organ 2010 ; 88 : 379 – 85 . Google Scholar CrossRef Search ADS PubMed 41. van Weel C . Primary health care and family medicine at the core of health care: challenges and priorities in how to further strengthen their potential . Front Med (Lausanne) 2014 ; 1 : 37 . Google Scholar PubMed 42. Strasser R . Rural health around the world: challenges and solutions . Fam Pract 2003 ; 20 : 457 – 63 . Google Scholar CrossRef Search ADS PubMed 43. Hanney SR , Gonzalez-Block MA , Buxton MJ , Kogan M . The utilisation of health research in policy-making: concepts, examples and methods of assessment . Health Res Policy Syst 2003 ; 1 : 2 . Google Scholar CrossRef Search ADS PubMed 44. Stenberg K , Hanssen O , Edejer TT , et al. Financing transformative health systems towards achievement of the health sustainable development goals: a model for projected resource needs in 67 low-income and middle-income countries . Lancet Glob Health 2017 ; 5 : e875 – 87 . Google Scholar CrossRef Search ADS PubMed 45. Kutzin J . Health financing for universal coverage and health system performance: concepts and implications for policy . Bull World Health Organ 2013 ; 91 : 602 – 11 . Google Scholar CrossRef Search ADS PubMed 46. Eijkenaar F . Key issues in the design of pay for performance programs . Eur J Health Econ 2013 ; 14 : 117 – 31 . Google Scholar CrossRef Search ADS PubMed 47. Duffy RD , Richard GV . Physician job satisfaction across six major specialties . J Vocat Behav 2006 ; 68 : 548 – 59 . Google Scholar CrossRef Search ADS 48. Spann SJ . Report on financing the new model of family medicine . Ann Fam Med 2004 ; 2 ( suppl 3 ): s1 – 21 . Google Scholar CrossRef Search ADS PubMed 49. Massoumi RL , Koduri S . Adverse effects of political sanctions on the health care system in Iran . J Glob Health 2015 ; 5 : 020302 . Google Scholar CrossRef Search ADS PubMed 50. Ng KH , Agius M , Zaman R . The global economic crisis: effects on mental health and what can be done . J R Soc Med 2013 ; 106 : 211 – 4 . Google Scholar CrossRef Search ADS PubMed 51. Lankarani KB , Alavian SM , Haghdoost AA . Family physicians in Iran: success despite challenges . Lancet 2010 ; 376 : 1540 – 1 . Google Scholar CrossRef Search ADS PubMed 52. Dieleman M , Cuong PV , Anh LV , Martineau T . Identifying factors for job motivation of rural health workers in North Vietnam . Hum Resour Health 2003 ; 1 : 10 . Google Scholar CrossRef Search ADS PubMed 53. Miedema B , Hamilton R , Fortin P , Easley J , Tatemichi S . The challenges and rewards of rural family practice in New Brunswick, Canada: lessons for retention . Rural Remote Health 2009 ; 9 : 1141 . Google Scholar PubMed 54. Rockers PC , Jaskiewicz W , Wurts L , et al. Preferences for working in rural clinics among trainee health professionals in Uganda: a discrete choice experiment . BMC Health Serv Res 2012 ; 12 : 212 . Google Scholar CrossRef Search ADS PubMed 55. Simoens S , Scott A , Sibbald B . Job satisfaction, work-related stress and intentions to quit of Scottish GPS . Scott Med J 2002 ; 47 : 80 – 6 . Google Scholar CrossRef Search ADS PubMed 56. Dehnavieh R , Rashidian A , Maleki M . Challenges of determining basic health insurance package in Iran . Payesh J 2011 ; 10 : 273 – 83 . 57. Dehnavieh R , Movahed E , Rahimi H , et al. Evaluation of the referral system in Iran’s rural family physician program; a study of Jiroft University of Medical Sciences . Electron Physician 2017 ; 9 : 4225 – 30 . Google Scholar CrossRef Search ADS PubMed 58. Norris TE , Coombs JB , Carline J . An educational needs assessment of rural family physicians . J Am Board Fam Pract 1996 ; 9 : 86 – 93 . Google Scholar PubMed 59. Ferdosi M , Vatankhah S , Khalesi N , Ayoobian A . Designing a referral system management model for direct treatment in social security organization . J Mil Med 2012 ; 14 : 129 – 35 . 60. Vosoogh Moghaddam A , Damari B , Alikhani S , et al. Health in the 5th 5-years development plan of Iran: main challenges, general policies and strategies . Iran J Public Health 2013 ; 42 ( suppl. 1 ): 42 – 9 . Google Scholar PubMed 61. Golalizadeh E , Moosazadeh M , Amiresmaili M , Ahangar N . Challenges related to second level of the referral system in family medicine plan: a qualitative research . J Med Council Iran 2012 ; 29 : 309 – 21 . 62. Kolozsvári LR , Rurik I . Evaluation of the quality of performance of general practitioners: what is the problem with primary care quality indicators in Hungary ? Orv Hetil 2016 ; 157 : 328 – 35 . Google Scholar CrossRef Search ADS PubMed 63. Rosen MA , Pronovost PJ . Advancing the use of checklists for evaluating performance in health care . Acad Med 2014 ; 89 : 963 – 5 . Google Scholar CrossRef Search ADS PubMed 64. Yazdi Feyzabadi V , Khosravi S , Amiresmaili M . Performance evaluation of rural family physician plan: a case of Kerman University of Medical Sciences . TB 2014 ; 12 : 48 – 59 . 65. Glanz K , Barbara K , Rimer K , Viswanat H. Health Behavior and Health Education: Theory, Research, and Practice , 4th edn . San Francisco, CA : Jonh Wily & Sons Inc ., 2008 . 66. Doshmangir L , Doshmangir P , Abbasi M , Rashidian A . Infrastructures for implementation of urban family medicine in Iran: infrastructures for implementation of urban family medicine in Iran . Hakim Health Sys Res 2015 ; 18 : 1 – 13 . 67. Moshiri E , Takian A , Rashidian A , Kabir MJ . Expediency and coincidence in the formation of family physician and universal rural health insurance in Iran . Hakim Health Sys Res . 2012 ; 15 : 288 . 68. Arya N , Gibson C , Ponka D , et al. Family medicine around the world: overview by region: The Besrour Papers: a series on the state of family medicine in the world . Can Fam Phys 2017 ; 63 : 436 – 41 . 69. Aligol M , Mohammadbeigi A . Assessment of private sector physicians’ willingness to participate in family physician program using the diffusion of innovation model, Qom, 2012, Iran . Qom Univ Med Sci J 2014 ; 8 : 27 – 34 . 70. Kabir MJ , Jafari N , Nahimi Tabihi M , et al. Health record and provided services recording among centers implementing rural family physician and insurance program in Northern provinces of Iran . J Hosp 2015 ; 14 : 61 – 9 . 71. Yazdi-Feyzabadi V , Emami M , Mehrolhassani MH . Health information system in primary health care: the challenges and barriers from local providers’ perspective of an area in Iran . Int J Prev Med 2015 ; 6 : 57 . Google Scholar PubMed 72. Jafarzadeh S , Mobasheri F , Bahramali E . Caregivers awareness about the rules of family physician program in Fasa in the year 2014 . J Fasa Univ Med Sci 2016 ; 6 : 326 – 33 . 73. Etemadi F , Malekafzali Ardakani H , Dejman M . Evaluation of public participation and intersectoral collaboration in family physician program in rural areas of Iran . Hakim Health Sys Res 2015 ; 18 : 182 – 93 . 74. Kabir M , Jafari N , Naeimi Tabiei M , et al. Rate familiarity of the members of local organizations in the Northern provinces of Iran about the family physician programme and rural insurance . TB 2015 ; 14 : 12 – 24 . 75. Cole AM , Chen FM , Ford PA , Phillips WR , Stevens NG . Rewards and challenges of community health center practice . J Prim Care Community Health 2014 ; 5 : 148 – 51 . Google Scholar CrossRef Search ADS PubMed 76. Manca DP , Varnhagen S , Brett-MacLean P , et al. Rewards and challenges of family practice: web-based survey using the Delphi method . Can Fam Phys 2007 ; 53 : 278 – 86 . 77. Appleton K , House A , Dowell A . A survey of job satisfaction, sources of stress and psychological symptoms among general practitioners in Leeds . Br J Gen Pract 1998 ; 48 : 1059 – 63 . Google Scholar PubMed 78. Cooper CL , Rout U , Faragher B . Mental health, job satisfaction, and job stress among general practitioners . BMJ 1989 ; 298 : 366 – 70 . Google Scholar CrossRef Search ADS PubMed 79. Dowell AC , Hamilton S , McLeod DK . Job satisfaction, psychological morbidity and job stress among New Zealand general practitioners . N Z Med J 2000 ; 113 : 269 – 72 . Google Scholar PubMed 80. Landon BE , Aseltine R Jr , Shaul JA , et al. Evolving dissatisfaction among primary care physicians . Am J Manag Care 2002 ; 8 : 890 – 901 . Google Scholar PubMed 81. McGlone SJ , Chenoweth IG . Job demands and control as predictors of occupational satisfaction in general practice . Med J Aust 2001 ; 175 : 88 – 91 . Google Scholar PubMed 82. Post DM . Values, stress, and coping among practicing family physicians . Arch Fam Med 1997 ; 6 : 252 – 5 . Google Scholar CrossRef Search ADS PubMed 83. Schattner PL , Coman GJ . The stress of metropolitan general practice . Med J Aust 1998 ; 169 : 133 – 7 . Google Scholar PubMed 84. Spurgeon P , Barwell F , Maxwell R . Types of work stress and implications for the role of general practitioners . Health Serv Manage Res 1995 ; 8 : 186 – 97 . Google Scholar CrossRef Search ADS PubMed 85. Sutherland VJ , Cooper CL . Job stress, satisfaction, and mental health among general practitioners before and after introduction of new contract . BMJ 1992 ; 304 : 1545 – 8 . Google Scholar CrossRef Search ADS PubMed 86. Khangah HA , Jannati A , Imani A , et al. Comparing the health care system of Iran with various countries . 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/about_us/legal/notices)

Journal

Family PracticeOxford University Press

Published: May 7, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off