This study was undertaken to identify the influencing factors on decision of GPs to join in UFPP in Iran. Since Iran is planning to develop UFPP to the whole country and maybe some other countries plan to implement it, identifying the factors affecting on join the GPs in the program is necessary. This issue is even more important where the ratio of GPs numbers to urban population is faced with a remarkable shortage. Thus, the results of this study provide evidence for policy makers to adopt suitable strategies and policies to overcome the barriers to join in the program.
This study has identified that higher age, working in public settings, lower self-reported income level, and lower level of perceived SES status, higher economic expectations, and satisfaction from the medicine major in GPs were the main factors that increase the probability to join in the UFPP. Although these factors might have grouped into push factors including demographics, practice and view/perspective dependent factors within and outside in the health sector separately, it is necessary to note that they might also interact with and influence each other (15).
The current study found that older GPs might have more tendency to join in the UFPP. In this regard, it seems that age is a personal factor which its impact is fluid and might be changed highly in matching with the career cycle (15, 19). It seems that older GPs have more family responsibilities (13) and they might be more risk averse since that they want to have more stable conditions professionally. The family physician program in Iran compensate their services on a basis of per capita payment system (3, 20). Thus, this may financially undergo less risk for the GPs with higher age.
Another result was that the GPs who are working in public sector (public clinics or hospitals) have more tendency to join in the UFPP as compared to those in private settings. This issue might be as a result of some reasons. First, GPs employed in public sector attain most of their income from outpatient visits and consultations based on public tariffs or fixed salary (3). So they prefer to practice as family physician which is similar to their current practice mechanism (visit based) but with a per capita payment system based on coverage of a defined population. This issue may increase their income level. Second, GPs employed in private sector almost practice without public sector limitations. In other words, they behave and practice freely than GPs in public settings. So GPs employed in private settings have less tendency to join in the program with some limitations. Nonetheless, it is necessary to be conducted further research for identifying the differences between the public and private settings which might affect the tendency to enter in the program.
The perceived SES and self-reported income level of the GPs might also highly affect the tendency to enter in the program. It seems that income level of each person has a direct relationship with her/his selected job. This issue is even more important in health care industry considering that the inflation rate in this sector is higher than other general sectors in the society (21). So, the less income and lower SES, the more tendency to join in the program will be. A recent study found that GPs are not satisfied with UFPP as it decreases their self-esteem and social status (22). The UFPP provide a stable and medium level of earning to GPs, therefore GPs with low income/low SES tend more to participate in the program. This finding is consistent with other studies conducted in health sector that income level has a considerable effect on the type of job that each worker in health sector might select (21, 23, 24).
One interesting finding is that GPs who are satisfied with their medicine profession, have a tendency more to enter in the program. This issue clearly indicates that job intrinsic motivations which are mainly intangible might to some degree be effective in joining in the program. It might also be noted that most likely the UFPP is compatible with the job intrinsic values in the medicine profession. This program provides serving to the community through more contact with the people. Also it is asserted by some authors that satisfaction from medicine profession can effect on physician' economic behaviors and decisions such as retention, target income, turnover and productivity (25).
The most interesting finding was that GPs with higher economic expectations might also increase the preference to enter in the UFPP. This issue can be explained by target income hypothesis (26). According to this theory, whatever the gap between actual and target income for GPs be more, they seek the ways to be enabled them to decrease the gap through attaining more income (27-29). So it seems UFPP might close the GPs to their target income or conform to their economic expectations. This emphasizes the importance and mix of the revenue generating activities in the health policies.
A key strength of our study was the variables explored are a relatively comprehensive set of potential determinants which may affect the decision to enter in the program especially those related to GPs' perspectives such as satisfaction and affection with the medicine profession and economic expectations. Since, as theoretically clarified in the literature, the decisions and behaviors of GPs are affected by the preferences and perspectives of them (30).
This study also had two main limitations. First, the findings may be somewhat affect by the sampling method. The participants (i.e. GPs) were sampled from a national educational congress conducted for GPs which many GPs presented from all of the country. This so may limit the generalizability of the study which it necessitates so we cautiously interpret the results. Second, the data produced were self-report; therefore, it maybe makes the measurement bias. However, it should be also noted that this is common in individual or household surveys (31).
In summary, this study is one of the first studies conducted to determine the influencing factors on the tendency the GPs to enter in the UFPP. As it explicitly is emphasized in the upstream documents, the establishment of referral system relied on primary health care and family physician for cities more than 20000 populations are a cornerstone in the future of Iranian health system. This study provided some preliminary evidence for identifying the factors affecting the GPs to tend for joining in the program. Furthermore, it also is necessary to be conducted further research with more depth and more rigorous methodology.