Table 2.
The main findings of 13 studies regarding the challenges associated with the infrastructure and structure of FPP
| Writer (year) | The infrastructural challenges | The structural challenges |
|---|---|---|
| Sarvestani et al. (2017)[8] | No attempts for acculturation Failure in expertizing the program | Treatment-based instead of prevention-based (deviation from the main goal) |
| Doshmangir et al. (2017)[5] | Current health insurance system was not ready to embrace a great health system reform such as FP Delayed reimbursement by health insurance to the family physicians Lack of a pooled fund and fragmented health insurance system Lack of a public insurance scheme Insufficient number of family physicians Lack of adequate financial resources, underestimation of the required funds for the plan, allocating the available financial support by entities other than the responsible institutions, lack of clear and stable financial resources for the program Lack of the necessary hardware platform and sufficient internet speed for the utilization of electronic health records (EHR) inadequate introduction of the FPP, not giving accurate and comprehensive information about the benefits and features of FPP to public. | Lack of a united health leadership and governance in the country Lack of cooperation between stakeholders, intra-/inter-sectional cooperation No rational medical tariffs based on relative value of health services |
| Fardid et al. (2019)[9] | Lack of health electronic records (fragmented databases) Lack of acculturation (patients insisting to the FPs for unnecessary referral to a specialist, resistance by the public and the specialist toward implementation of the program) Multiple insurance funds. | Violation of the regulations by the FPs Inadequate regulations (such as working hours of FPs until 12 in morning) Delayed payments to the FP Spending the allocated budget for other purposes |
| Mehrolhassani et al. (2021)[14] | Hasty implementation of the program without addressing the infrastructure Lack of necessary software Lack of strong information technology infrastructure Lack of access to Internet in the offices Lack of proper health-based and preventative health care education for FPs Neglecting culture building and lack of acculturation Insufficient attempts to properly introduce the program and provide sufficient information to the public Long delay (years) in payment of the approved budget for the UFPP Multiple insurance organizations and policies The payment and service purchase system: “per capita” payment to the family physicians and their teams as and “single payment” for levels 2 and 3. | Government transitions lead to new plans regardless of previous efforts Government transitions lead to the replacement of policy-makers Considering political factors instead of expertise-oriented factors for selecting officials Lack of a well-considered plan for health, treatment, and health education (the education system failed to prepare the family physician) No effective interaction between different levels of the referral system Weakness of inter- and intra-sectoral communication |
| Dehnavieh et al. (2015)[7] | Hasty implementation of the program Starting the FPP before integrating the existing insurances Insufficient financial resources Lack of backup software for methods of payments Neglecting culture building and lack of acculturation Insufficient attempts to properly introduce the program and provide sufficient information to the public Insufficient number of physicians with the required skills and education Inappropriate physical space. Shortage and poor distribution of resources. Problems related to the patient’s electronic file. | Delay in payments Lack of a united leadership Weakness of financial processes Lack of effective supervision on payment methods in the cities Incomprehensive, confusing, and unclear laws and regulation Inappropriate communication between providers Long delay before sending out the memorandum and instructions Work overload of physicians |
| Lack of a coherent information bank Unclear methods of payment to other forces. | ||
| Shiyani et al. (2016)[16] | Weakness of health educational system in providing health-based training for family physicians and helping them develop the adequate skills and competency. | Lack of a united leadership and governance and fragmentation of health policy making Inadequate laws on the responsibilities of each sector Inadequate operation supervision of physicians’ and patients Chaos in the health system Neglecting the multi-disciplinary nature of the health system by policy makers Conflict of interests of the FPP with Ministry of Health Body, the physicians’ union and the private sector, prioritizing personal interests over community interests Using a top-down approach instead of a participatory approach Medicalization of management (selecting physicians as managers, which leads to management inefficiency and conflict of interest in the policy-making process) Prioritize the organizational perspective over the technical perspective |
| Bolbanabad et al. (2019)[13] | Lack of manpower and facilities for treating emergency patients Insufficient attempts to properly introduce the program and provide sufficient information to the public Neglecting the culture building process by the program managers No educational program for the health workers in FPP Providing treatment-based medical education in the universities Delay budgeting Insurance deductibles Not providing para clinical services in the centers Lack of adequate facilities in comprehensive health centers Lack of comprehensive and coherent health records Lack of the required infrastructure for electronic health record systems Failure to send correct information to higher levels Lack of health-oriented vision of insurance Lack of proper supervision structure in the insurance organization. | Frequent changes in FPP Lack of a proper monitoring and control mechanism Failure to follow the rules and instructions correctly Weakness in attracting cross-sectoral cooperation and inadequate cooperation of intra-departmental units |
| Farzad Far et al. (2018)[17] | Unclear payment methods Delays in payments Problem in providing the budget Insufficient attempts to properly introduce the program and provide sufficient information to the public Inconsistency of the general practitioner training curriculum with the FPP Treatment-based and not prevention-based education Lack of training and retraining for staff Insufficient number of medical centers and medical equipment. | Unclear job description Writing the program’s executive protocol with a one-dimensional view Lack of a clearly defined monitoring system Frequent change of management of the FPP |
| Kaskaldareh et al. (2021)[18] | Lack of IT specialists in the health care network Difficult access to the networks Low integration of the existing information systems Middleware bugs Lack of proper hardware and software Lack of budget. | Frequent change of management of the FPP Unclear payment methods Failure to register information because of a high number of clients Poor inter- and intra-sectoral cooperation |
| Damari et al. (2017)[19] | Lack of a united leadership and governance in the referral system Role conflict and ambiguity between the Ministry of Health and Medical Education and the Ministry of Cooperatives, Labour, and Social Welfare Weaknesses in inter-sectoral and intra-sectoral cooperation Weaknesses in multi-level service evaluation and monitoring | |
| Alaie et al. (2020)[20] | Lack of culture building (via educational systems and mass media such as TV) Lack of budget allocation Treatment-based education Inadequate budget for insurance. | Conflict of interests (physicians as policy makers with clear interest in the program, conflict of interests between the physicians and the specialists and between the Ministry of Health and Ministry of Cooperatives, Labour and Social Welfare) Lack of trans-sectoral perspective in health care decision making Lack of coordination between the treatment sector and prevention sector of the Ministry of Health Dependency of the progress of the program on individuals and governments Lack of a united management on a national level Lack of a national policy for tariff Neglecting the role of research in policy making One-dimensional approach to health policy making Lack of an effective cooperation between the Ministries of Health and Medical Education and the Ministry of Cooperatives, Labour and Social Welfare Using a top-down approach instead of a participatory approach Unclear job description |
| Hooshmand et al. (2020)[21] | No pilot before implementation of the main FPP Inadequate housing and welfare infrastructure for human resources Inadequate transportation facilities for human resources Lack of public awareness Inadequate training for service providers Lack of valid and reliable checklists for FPP assessment Delays in payment Inadequate criteria for per capita income definition Insurance deductibles. | Lack of inter- and intra-sectoral cooperation |
| Abedi et al. (2017)[15] | Hasty implementation of the program without proper assessment of the structure and resources Lack of human resources specially in the private sector Lack of proper training based on the program requirements Lack of a legal mechanism to ensure the needed office space for the family physicians in the private sector Inadequate number of facilities specially in the private sector No infrastructure for electronic health records Using a per capita model instead of a function-based model for payments to the health care team Lack of expert insurance inspectors to assess the function of physicians. | Insufficient regulations for the presentation and implementation of the service package of the FFP Lack of inter- and intra-sectoral cooperation |