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

Strategies for improving the financing of family medicine program: Evidence from Iran

Background and Aims

The impact of health financing on the performance of the entire health system, including access, quality, and efficiency of healthcare, has been emphasized in the Astana Declaration, and the need to strengthen primary healthcare (PHC) and policy integration has been emphasized. After about two decades, the family medicine (FM) program in Iran is still facing great challenges. The aim of this study is to explore strategies for strengthening financing of the FM program in Iran, a vital component of PHC.

Methods

A qualitative study was conducted in 2021. Purposeful sampling was used to select 34 policymakers, managers, and experts from various levels of the Ministry of Health, Iran universities of medical sciences, plan and budget organization of Iran, and health insurance organization in Iran. Thirty-four semistructured interviews were conducted to collect data, which were analyzed by content analysis.

Results

Through the analysis of interviews, our study has identified five strategies (identification and management of sustainable resources, pooling of sustainable resources, modeling of service provision, payment system model and its implementation process, and FM management structure), and 13 actions for strengthening financing of the FM program in Iran.

Conclusion

Our study has identified five strategies and 13 actions for strengthening the financing of the FM program in Iran. These strategies and actions should be considered by policymakers during the review of the FM program in Iran. Without implementation of the suggested strategies and action, allocated resources may be wasted.

Development and validation of primary health care quality assessment tool

BACKGROUND

Assessing the quality of health services gives insights to managers about the status of services delivered by them, especially from the client's perspective. Although various tools have been developed to measure the quality of primary health care (PHC), no specific tool was found in this field in Iran. Therefore, the present study was conducted to develop and validate the quality assessment tool of PHC in Iran.

METHODS

This methodological study was conducted in 2021. In the first step, based on a literature review, an initial questionnaire was designed, and its face validity, content validity, construct validity, and reliability were evaluated. Descriptive tests, Kolmogorov-Smirnov, exploratory factor analysis, Kaiser-Myer-Olkin (KMO), and Cronbach's alpha were performed by using SPSS 22.

RESULTS

The initial questionnaire included 33 items, of which three items were removed due to inconsistency with factorization. The final questionnaire consisted of 30 items and nine dimensions: interaction, efficiency, timeliness, accuracy, consultation, tangibility, safety, accessibility, and environment. The KMO and Cronbach's alpha index values were 0.734 and 0.82, respectively, indicating acceptable reliability and validity. The developed dimensions represented about 73% of the total variance.

CONCLUSION

The designed questionnaire has relatively good validity and reliability and can be used to measure the quality of PHC and to identify weaknesses in service delivery. However, researchers should carefully examine it to enhance its applicability as a standard tool for measuring PHC quality.

Financial challenges in the family physician programme in Iran: A systematic review of qualitative research

Introduction

The family physician programme (FPP) was implemented nearly two decades ago as a major health reform. Since the health system and FPP function in a rapidly changing social and economic environment, successful expansion of the programme requires a detailed analysis of its multiple major challenges, including the crucial aspect of its funding system. This systematic review aimed to assess the challenges in the FPP relative to its financing.

Method

All published articles related to the FPP in Iran were included in this study. In particular, original qualitative studies published in English or Persian from 2011 to 2021 were included. In January 2022, international credible scholarly databases and Persian databases were searched. All selected articles were carefully studied, and the data were extracted using the sample, phenomenon of interest, design, evaluation and research type technique. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses were used in preparing the study report.

Results

Among 491 articles retrieved from the search strategy, 50 met the inclusion criteria after their titles and abstracts were screened. Twenty-nine studies were excluded after their full texts were reviewed. A total of 11 eligible empirical studies were finally included. Based on the results, six broad categories (budget and funding, insurance system, tariffs, payments, accountability and injustice) were identified as financial challenges.

Conclusion

This study identified the challenges associated with financing among family physicians, and the results could provide guidance for policy-making in the expansion of the FPP.

The causal effect of family physician program on the prevalence, screening, awareness, treatment, and control of hypertension and diabetes mellitus in an Eastern Mediterranean Region: a causal difference-in-differences analysis

BACKGROUND

Hypertension (HTN) and diabetes mellitus (DM) as part of non-communicable diseases are among the most common causes of death worldwide, especially in the WHO's Eastern Mediterranean Region (EMR). The family physician program (FPP) proposed by WHO is a health strategy to provide primary health care and improve the community's awareness of non-communicable diseases. Since there was no clear focus on the causal effect of FPP on the prevalence, screening, and awareness of HTN and DM, the primary objective of this study is to determine the causal effect of FPP on these factors in Iran, which is an EMR country.

METHODS

We conducted a repeated cross-sectional design based on two independent surveys of 42,776 adult participants in 2011 and 2016, of which 2301 individuals were selected from two regions where the family physician program was implemented (FPP) and where it wasn't (non-FPP). We used an Inverse Probability Weighting difference-in-differences and Targeted Maximum Likelihood Estimation analysis to estimate the average treatment effects on treated (ATT) using R version 4.1.1.

RESULTS

The FPP implementation increased the screening (ATT = 36%, 95% CI: (27%, 45%), P-value < 0.001) and the control of hypertension (ATT = 26%, 95% CI: (1%, 52%), P-value = 0.03) based on 2017 ACC/AHA guidelines that these results were in keeping with JNC7. There was no causal effect in other indexes, such as prevalence, awareness, and treatment. The DM screening (ATT = 20%, 95% CI: (6%, 34%), P-value = 0.004) and awareness (ATT = 14%, 95% CI: (1%, 27%), P-value = 0.042) were significantly increased among FPP administered region. However, the treatment of HTN decreased (ATT = -32%, 95% CI: (-59%, -5%), P-value = 0.012).

CONCLUSION

This study has identified some limitations related to the FPP in managing HTN and DM, and presented solutions to solve them in two general categories. Thus, we recommend that the FPP be revised before the generalization of the program to other parts of Iran.

Challenges in the implementation of an electronic referral system: A qualitative study in the Iranian context

Referral chain reduces patient costs and results in more efficient use of workforce and equipment. Despite the implementation of the Family Physician Programme in Iran, the referral system does not function as intended. Therefore, this study was conducted to explain the challenges in the implementation of an electronic referral system in Iran. This qualitative study was performed in Golestan province in northern Iran. The participants were 46 family physicians, specialist physicians, healthcare managers, experts, and patients who were selected through purposive sampling. Data were collected using in-depth individual interviews and were analysed using content analysis. Implementation of the electronic referral system faces management challenges (planning, organisation, motivation, control), administrative challenges (scheduling, patient load and waiting time, visit and diagnosis, feedback), and educational, policy, sociocultural, technological, and economic challenges. Policymakers can adopt appropriate strategies to improve the quantity and quality of their electronic referral system according to the challenges identified herein.

Interpersonal Continuity of Care and Its Effect on Health Care Utilizations and Expenditures for Diabetes: An Experience From a Fragmented Health System

We aimed to quantify continuity of care (COC) and investigate its association with health care utilizations and expenditure among patients with diabetes. This was an observational retrospective cohort study using administrative claims database of Iranian Health Insurance Organization for East Azerbaijan Province, Iran. Standard indices of COC were calculated for each patient, and their associations with utilization outcomes were determined by applying general linear regression models. A total of 32 263 patients were included (mean age: 60.9 ± 14.5 years; 64% females). Higher levels of COC were associated with a reduced number and spending of all health care service categories.

Pay-for-performance challenges in family physician program

OBJECTIVE

This study was conducted to investigate the challenges faced in the implementation of the pay-for-performance system in Iran's family physician program.

STUDY DESIGN

Qualitative.

PLACE AND DURATION OF STUDY

The study was conducted with 32 key informants at the family physician program at the Tabriz University of Medical Sciences between May 2018 and June 2018. Method: This is a qualitative study. A purposeful sampling method was used with only one inclusion criterion for participants: five years of experience in the family physician program. The researchers conducted 17 individual and group non-structured interviews and examined participants' perspectives on the challenges faced in the implementation of the pay-for-performance system in the family physician program. Content analysis was conducted on the obtained data.

RESULTS

This study identified 7 themes, 14 sub-themes, and 46 items related to the challenges in the implementation of pay-for-performance systems in Iran's family physician program. The main themes are: workload, training, program cultivation, payment, assessment and monitoring, information management, and level of authority. Other sub-challenges were also identified.

CONCLUSION

The study results demonstrate some notable challenges faced in the implementation of the pay-for-performance system. This information can be helpful to managers and policymakers.

Family physician model in the health system of selected countries: A comparative study summary

BACKGROUND

In the 21st century, with the epidemiological and demographic transition and the changing nature of diseases and the increase in the burden of chronic diseases, the need to strengthen primary health care and the development of the family medical program as a strategy is felt significantly.

AIM

The purpose of this study is to compare the model of implementation of family physician program (FPP) in the United States, England, Germany, Singapore, Turkey, Egypt, and Iran.

MATERIALS AND METHODS

This is a comparative study that examines the model of family physician implementation in selected countries. Data for each country were gathered from the valid databases, were compared according to the comparative table, and analyzed by a framework approach. In order to assure the validity of data, the researchers referred to the websites of the selected nations' Ministry of Health and also cross-checked the findings with reports published by the World Health Organization.

RESULTS

In this study, we used the Control Knobs framework to compare countries' FPPs because the framework can demonstrate all necessary features of national health system programs. This framework includes governance and organization, regulation, financing, payment, and behavior in each country. The results of this study show that although the principles of FPP in the selected countries are almost common, they use different methods in FPP implementation.

CONCLUSIONS

As the success of any policy depends on the political, economic, social, and cultural context of each country, considering these factors and reinforcing each of the control knobs are critical to the success of the family physician's policy implementation.