Dimension 1: Underlying factors
Main Category 1: Situational factors
Subcategory 1: Managerial factors
Precipitancy in decision-making means that a decision is made before the necessary tools are provided and it is implemented before being practically possible. This was evident in the participants’ statements.
"Unfortunately, in Iran, the family physician has fallen victim to the precipitancy of governments, so that at the end of the eighth government, the family physician program began in the villages without a proper infrastructure. Also, at the end of the tenth government, the expansion of family physician program all over the country was considered, and the result of these hasty actions is what we see in Fars and Mazandaran provinces."(M 4)
Change of government: The programs of health system in Iran are affected by the change of governments and ministers. With the departure of each government, a new minister takes the office and the new minister, regardless of previous efforts, launches a new plan. This issue has been more prominent in the family physician program, especially at its beginning.
"One of the problems is that in our country, governments are formed and ended every four years. In the first year everyone is a novice and begin to learn about issues. They began to work in the second and third years, and in the fourth year they leave the office. In such a system, it is not possible to implement a longitude and time-consuming program such as family physician."(M 3)
Subcategory 2: Economic conditions
Sanction on medication: According to the respondents, the impact of political and economic sanctions on the health sector has been more prominent in the pharmaceutical sector and medical equipment.
"I think we have implemented this plan when we really have a drug crisis in the country. I have been the vice-chancellor for food and medicine at the university for about 10 years now, and I can safely say that, things have not been worse than this ten years. That means people had been faced with a new plan and when they were going to get a prescription, they were constantly hearing; “we do not have it”. We are under sanctions. This has had a negative effect." (M 14)
Economic sanctions: Sanctions imposed on Iran’s economy by the international community have directed the financial and economic resources of social programs to areas that have higher priority. Obviously, the lack of funding for the program has affected the implementation of program.
"Of course, the government also has financial problems ... The government now runs the country with taxes and most of the oil revenue is not available." (M 5)
"The issue of payments, medicine, salaries of executive staff and assistants, and also the physician per capita have a significant and direct relationship with the sanctions." (M 25)
Inflation: Iran had the highest inflation rate in the early years of urban family physician program implementation.
"If the family physician program is implemented properly, it will be economically beneficial for people, because now they pay 10% of the visit fee, but they used to pay 30%. The medicine is also free, but if there is inflation, it affects everything, not just the health." (M 23)
Main Category 2: Structural factors
Subcategory 1: Political factors
Politicization means the removal and selection of ministers and officials by political-factional motives, and ignoring the principle of selecting people with right expertise and appropriate characteristics in all areas, even non-political areas such as social service and economy.
"In the social service sector, officials should not have a political view, so that when the government changes, they should not change everyone due to political views." (M 5)
Change of policymakers: In addition to change of government, as one of the transient factors (situational factors) that has played an important role in the family physician program, changing policymakers and ministers, and the unsustainability of health system (as a structural factor) has caused plans and programs to be implemented in a short time.
"Unfortunately, after the revolution, none of the health ministers has been in the office for two consecutive terms, and this in itself is one of the most important factors that cause the minister to look for programs with quick returns, and these quick returns make everyone to miss the details.... Experience has shown that when you work on a structure when reforming a sector, the results will be more sustainable."(M 7)
Subcategory 2: Economic factors
Employment and migration of graduates: The existence of a large population of young and educated people on the one hand is considered as economic capital and on the other hand, it is considered as a serious and potential threat in Iran. Low recruitment among medical graduates is also one of the problems that officials are faced with, which affects the process of planning and implementing employment programs.
"If family physician program is implemented, medical graduates will not be unemployed."(S 2)
"In principle, the identity of general practitioner has been questioned. So, the general practitioners either migrate or chose another job, and that is the fate of general practitioners. Unfortunately, many general practitioners are unemployed." (M 12)
Subcategory 3: Social factors
Material motives: Contrary to the approach of older physicians in providing services to the people, the formation of some kind of material motives among physicians has damaged the health system programs. The interviewees believed that, this has led to discrimination and affected the urban family physician program.
"It has become difficult to meet the expectations of physicians, whether general practitioners or specialist physicians, who must be satisfied. Nowadays, it takes much more to fill the mouths of physicians." (M 5)
Subcategory 4: Structural disorganization
Lack of a plan: The health system does not have a well thought written plan for health, treatment and education of health system.
"How did the health reform program or family physician program come about? Did the high ranking officials decide it or not? It was not a matter of sitting down and writing a program and determining the status quo, saying that this is the situation and this should be the standard status, or covering the gaps in these programs."(M 7)
"The lack of a master plan (for example, a 20-25 years or a long term program) has led our education system not to be able to adapt to the concept of family physician. So in this situation, physicians become graduated while they are not prepared for such programs." (M 4)
Main category 3: Cultural factors
Subcategory 1: Religion
Gender differences: According to the interviewees, having religion did not have much effect on referrals to family physicians and the role of religion was more seen in the gender differences within family physicians. Some female patients, despite having a male physician, prefer to see a female physician.
"Many of our physicians are men. Some people, whether women or their spouses, do not want the family physician to be in the midst of their family problems, so we had a series of challenges in this regard. However, some solutions were also proposed. For instance, the assistant of a male physician must be a woman (a female nurse or midwife). In this regard, another challenge is that many people do not believe in midwives or nurses, and the interesting thing is that, they still do not allow a male physician to visit them." (M 35)
Subcategory 2: Beliefs
Believing in traditional medicine:
Some people believe in traditional medicine, and do not visit family physicians. This issue created many problems for the program.
"We have people in our target population who go to see our colleagues who are traditional medicine specialists. Well, they have to pay all the costs out of their pocket." (M 40)
Believing in the expertise of previous physician:
Before the implementation of urban family physician program, people were free to see a physician and usually referred to a specific physician. Changing physicians has created some problems by limiting the population covered.
"Unfortunately, the biggest factor that has caused dissatisfaction among clients is that some of the physicians may have an effective treatment method or higher experiences, and almost all clients only believe in these few physicians." (M 38)
People's belief in the status of family physician: Another cultural issue has been the status of family physician (compared to specialist physicians) among people. Since the current culture of Iranian people is to consult a specialist for most diseases, it is difficult for them to accept that fact that, they should consult a general practitioner (in the form of a family physician) for most diseases.
"When a physician does not have power and authority within society, people do not accept him and therefore, may not trust him." (M 5)
Main category 4: External factors
Subcategory 1: World ranking of countries
The world ranking of countries: External factors can have an impact on health programs and systems even from outside the organization or country. One of the external factors that the interviewees emphasized on, was Iran's ranking among the countries in the region and the world in terms of health indicators.
"Iran ranks low among the countries in the region and has a long way from the goals set in the existing policies of the country, which indicate that Iran should be ranked first in the region in terms of health indicators. The implementation of family physician program has been one of the most important efforts of policymakers to fill the gap and reform the health system." (S 10)
Dimension 2: Establishment and implementation of urban family physician program
In regard to establishing and implementing the family physician program, 6 main categories, 9 sub-categories and 14 codes were extracted from the participants’ statements as seen in Table 3.
Main Category 1: Financial resources
Subcategory 1: Insurance
Diversity of insurance organizations: Diversity of insurance in the country and the existence of insurance organizations with different policies, including health care and social security insurances, along with various insurances such as oil industry, banks and other companies caused many problems in the implementation of family physician program at the beginning.
"Family physician program has been implemented mainly in countries that either followed the NHS system or had integrated insurance funds. In countries that have different funds with different policies, implementing a family physician program is very worrying." (M 5)
Interaction between the health system and insurance organizations: One of the issues in the implementation of urban family physician program is related to how the health system interacts with insurance organizations. According to the opinions of participating experts and the provincial documents obtained from the coordination meetings of the officials in these areas, contrary to the beginning of the program, in the following months of the program, coordination had been made between the family physicians and insurance companies at least at the provincial and lower levels, so that the physicians were accepting the insurance cover of these companies.
"In my opinion, this coordination was great both at the provincial level and at the national level. But the problem was that, enough credit was not being given to the program." (M 23)
Payment and service purchase system: Payment to the providers of urban family physician program has been defined for the family physician and his/her team as “per capita”, and for levels 2 and 3 as single payment.
"The family physician's fee is paid as per capita. The basic per capita payment for the physician and his/her team increases per person according to special cases. However, the specialist or subspecialist physician’s fee for inpatient services is paid as per hour." (S 1)
"If a family physician, for any reason, refers one of his / her client to a specialist, he / she will receive 90% of the private visit fee and 100% of public visit fee from the insurance companies if the patient goes to private sector, and if he goes to public sector, the he/she will receive the fee for 3 public visits from the insurance companies."(S 1)
Subcategory 2: Budget
Budget provision: According to the senior managers of the Ministry of Health, the financing of this program has had many ups and downs, which has affected the program’s objectives. According to the reviewed documents, the budget required for the urban family physician program has been foreseen and approved in the budget law, but has not been provided for years due to various reasons (including change of ministers and government).
"Providing resources is another issue in this area. For example, 2011 was the first year that the family physician program wanted to start, but there was no budget." (M 5)
Budget allocation: Allocation and use of provided budgets guarantees the implementation of urban family physician program in the two provinces, which requires the efforts of officials of the family physician program; an action that has not been taken place in years and has had its impact.
"The 11th government that came to power did not have a plan to provide and allocate budget for the program, and this was practically postponed until the end of year." (M 6)
Main Category 2: Structures and communications
Subcategory 1: Communication between levels and organizations
- Referral system: In the urban family physician program, an effective referral system ensures close communication between all three levels of the health system, including family physician, specialist physician and highly specialist physician. It also helps people to receive the best possible care in the nearest location.
"Providing level 2 and level 3 infrastructures is very important. If by level 2 of family physician program we mean a specialist who is sitting in his office, then we must admit that the infrastructure is not ready yet." (M 24)
Another issue is the effective communication between the various levels of referral system.
"We are only referring to the second and third levels, but unfortunately, we do not have a valuable feedback. I do not remember the exact number, but during the time I have been referring clients, maybe I have just referred 5 or 6 clients that gave me a valuable feedback, which had an educational advantage for me."(M 37)
The coordination between family physician at the first level and the specialist physician at the second level, according to the family physicians, was limited to a referral sheet, and there was no any other communication.
"Specialist physicians have virtually no communication with the family physicians, so much so that they only know that the referral sheet consists of two pages, with one side written by the family physician and the other by them writing back to the family physician." (M 38)
Inter and intra-sectoral communication: Inter and intra-organizational coordination at different levels is of particular importance. At the city and provincial level, the coordination between various deputies in medical universities, as well as the coordination between the family physician team and other departments for the proper implementation of referral system is one of the factors that play an important role in advancing the work.
"The university dean was definitely in the meetings that they were holding, and if he wasn’t, he would have asked some else to represent him. But the reason for the lack of coordination was that, the therapists thought that it is the responsibility of health system, which was not the case. However, some coordination between us was good. “(M 22)
Main Category 3: Information technology
The advanced health systems in the world are equipped with powerful and advanced information systems. Information technology is useful for the family physician and also it is a necessity for access to an advanced health system.
Subcategory 1: Software
Electronic file: Urban family physicians need information recording software, which not only provides the physician with the client’s information centrally, but also provides the program managers with more comprehensive information such as medication and equipment, the type of services provided to client and his communication with different levels.
"A big problem of family physician program was the software, as the Iranians’ health software was also the software of the program. We entered the patent’s previous information, medical history and national code and we were online. The big drawback was that, the program software was being upgraded, which meant that we didn't have the upgraded software, while starting the program. We were saying, let’s start the program. However, when we started the program, four months later, we found out that we need this and that in the system, which was not even ready for six months. After six months when the system was finally ready, we saw that the system is wrong here or does not work there." (M 23)
Lack of strong information technology infrastructure was another serious obstacle to the urban family physician, which needed to be resolved at the highest levels of the health system.
"Certainly, completing and strengthening the IT infrastructure in the country is very important for electronic files, copying and electronic referrals, etc., and with the improvement of this system, the work will become much easier." (M 12)
Subcategory 2: Electronic networks
Internet: The existence of software and electronic records requires access to the internet in both public clinics and private offices. Participants believed that:
"At the city level, we had no problem in terms of hardware infrastructure in public sector, as we had prepared all these facilities before the official implementation of program. But in the private sector, this infrastructure was not ready, and even to this day, some physicians have not done their work in their office."(M 22)
Main Category 4: Human resources
The required human resources in the urban family physician program include the family physician specialist and his/her team.
Subcategory 1: Education and empowerment
A family physician is a specialty, which generally has a preventive and health-centered approach rather than treatment approach.
Education system: From the beginning, the medical education system in Iran has trained general practitioners with an emphasis on the centralized treatment approach, and therefore, it cannot easily cope with the family physician’s health-centered approach and achieve its goals.
"One of the problems we have is that, our physicians are not family physicians, they are therapists. We trained them this way and this is not their fault. So, both the science we taught them and their role model were different. We all earn money from treatment, not health and prevention. These physicians have had no proper education on health and prevention, have not had proper observation of models, and even have no income from health and prevention, so they just sit in their office and write prescription." (M 1)
"This is one of the problems we have. From time to time, if meetings are held for family physicians to express their problems and offer solutions, it will be much better, but unfortunately, this does not happen at all." (M 40)
Subcategory 2: Weakness in expertise
Experience of ministers: The policymakers of family physician program have not had enough experience and expertise to manage the health care system and consequently, the urban family physician program. Since it takes at least a few months for a minister to take the office, it takes him or her a while to figure out what the program means and what the plans are. So, the lack of experience of people who are appointed as ministers in this area may have negative effect on the implementation of program.
"Among the five ministers of health that we had during the implementation of family physician program, except for Dr. Pezeshkian, who was the deputy minister, none of them had any experience in the country’s senior management." (M 5)
Main Category 5: Information sharing and culture building
Part of the implementation of family physician program is related to information sharing and culture building. In this regard, topics such as building culture for the program among people and service providers are important.
Subcategory 1: Education and people preparation
Culture building: In order to implement the urban family physician program, cultural work had to be done actively to form the public mentality towards the program, and one of the reasons for the increase in dissatisfaction and complaints about the urban family physician program has been related to this issue.
"If this program had been well explained to people, we would have created a good culture. Maybe if we would have spent a few years explaining this program to people, we were not having the problems that we are dealing with now." (34)
Information sharing: Insufficient sharing of information before the implementation of program has caused many problems for the program providers, including the large number of people visiting the family physicians at the beginning of the program, disruption of patient referral process and client dissatisfaction.
"The media, except for television, especially the provincial television, did not advertise the program. Newspapers were less involved in the program. Television had a weekly interview and gave the report or provided guidance." (M 23)
Main category 6: Facilities and equipment
Subcategory 1: Physical space and facilities
The physical space, facilities and equipment necessary for the implementation of family physician program were among the infrastructures that, according to the program implementers, had been provided, especially in the public sector and before the implementation of program.
"We had no problem with the hardware ...... There was no problem with the location and physical space." (M 23)
"We had no problem at the city level in terms of hardware infrastructure in the government sector ... We easily prepared these kind of facilities even before the official implementation of program.” (M 22)