Prioritizing implementation solutions for the urban family physician policy in Iran: a multi-criteria decision-making study

Abstract

Background

Family physician program is one of the effective reforms of the health system in Iran, but despite the implementation of this program in rural areas and the passage of ten years since its implementation in two provinces of Fars and Mazandaran, its implementation has faced problems. The aim of this study is to identify and prioritize implementation solutions related to the challenges of the family physician program in Iran.

Methods

This is a qualitative study using semi-structured interviews with 22 snowball-sampled experts and managers of basic health insurers to extract problems and executive solutions through coding and data analysis using Atlas Ti software and content analysis in the first stage. The combined criteria were used to report qualitative studies (COREQ). In the second stage, the extracted executive solutions were ranked using multi-criteria decision-making (MADM) and a hybrid approach combining Shannon entropy with simple aggregation weighting (SAW).

Results

Main themes were identified, including financing, management, human resources, structure, culture building, payment mechanism information systems, monitoring & control, performance of insurance organisations, and implementation. Out of these, priority was given to the information system, along with 41 sub-themes prioritising comprehensive, community-oriented physician training.

Conclusion

The findings of the study provide remedies for the problems of the Iranian Urban Family Physician Programme at the executive level and in priority order, from the standpoint of the insurance organisations. Making crucial decisions entails handling matters relating to funding, administration, personnel, architecture, ethos, remuneration, IT systems, oversight, insurance organization output, and execution.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-025-12291-x.

Background

The primary healthcare strategy for achieving health for all by the year 2000 was introduced by the World Health Organization during the Alma-Ata Conference in Kazakhstan in 1978 [1]. Among the most crucial interventions proposed to enhance quality, cost-effectiveness, and access to health services was the family physician program [2]. Countries such as United Kingdom, Denmark, Norway, Spain, and the Netherlands have shown the success of implementing family screening programs as the mainstay of health systems [3].

Iran’s Ministry of Health and Medical Education oversees public health through a three-tier health network: First level: Units such as village health houses, urban health centres and rural and urban health centres serve as the community's first and most comprehensive contact with the health system. These centres are staffed mainly by nurses. second level: This level includes more specialised health and treatment services provided by health centres and city hospitals. General practitioners, together with other health professionals, provide diagnostic facilities such as laboratory and radiology services, dentistry and midwifery, third level: Specialised and sub-specialised hospitals within the provincial health centre provide advanced training services and complement the second level. Medical and paramedical training is often provided at this level.

The family physician and referral system, based on the law of the Fourth Development Plan, was decided to be implemented by the end of 2014 [4]. As a result, it was implemented in rural areas and towns with less than 20,000 inhabitants from 1384, and as an experiment in the urban population of Mazandaran and Fars provinces from 1391 [5].

The family physician program is a comprehensive health care system. Its primary outcome is to reduce people's confusion about consulting a physician and to increase their satisfaction with health care services [6, 7]. Additionally, several studies have validated that family physicians can render more efficient care for the prevention, treatment, and management of particular diseases while consuming fewer resources [8, 9]. On the contrary, disregarding the family physicians and referral system can break the connections within the healthcare delivery system, resulting in heightened expenses and diminished service quality [10]. Several factors influence the success of the GP program, defined primarily as the allocation and securing of financial resources and the design of appropriate payment schemes, the education of staff and the general public, the involvement of the media in education, the restructuring of the medical education curriculum, the involvement of the private sector and specialists, and ensuring the continuity of the program [11]. Establishing suitable organizational structures and protocols, coordinating inter-sectorally and intra-sectorally, and receiving backing from policy-makers are vital for the success of the family physician program. Despite the program's accomplishments, various studies [4, 12, 13] have identified challenges in executing the program, but only a small number of studies [14, 15] have focused on resolving these issues. Also so far there has not been a specific study from the point of view of insurance organizations (as the most important stakeholders of the program), so the purpose of this study is to identify and prioritize implementation solutions related to the challenges of the program; Therefore, the aim of this study is to identify and prioritize implementation solutions related to the challenges of the Family physician program in Iran.

Methods

The study is qualitative and conducted in two phases. Firstly, executive solutions were extracted through semi-structured interviews. In the subsequent phase, these solutions were prioritized using multi-criteria decision making (MADM) and a hybrid approach of Shannon entropy and simple additive weighting (SAW) (this study is the second phase of another study [16] (Multi-criteria decision-making refers to a method of a set of decision-making techniques that includes a set of quantitative and qualitative factors. In this method, the opinions and goals of multiple decision-makers are clearly combined, and the decision-makers are allowed to rank the observations, criteria, and the importance of each of them, and resolve the inconsistencies despite the conflicting and opposing opinions. In these decisions, several criteria are used instead of one criterion for measurement. SAW is one of the simplest and oldest methods of multi-indicator decision-making, which will be described below. The snowball sampling method was used for participant selection (see Table 1). The data collection method was a semi-structured interview (Additional file 1), which started with the main question: What do you believe is the appropriate solution to the challenges of the family physician programme? Interviews continued until data saturation, encompassing 22 interviews, conducted in person and individually. Participants provided informed consent before recording. Note-taking was employed during the interview, and the text was immediately transcribed thereafter. The data was coded and categorized using Atlas-ti software. The content analysis employed an inductive approach. The study's unit of analysis was the interviews, which were thoroughly reviewed after transcription. The meaning units were then identified as sentences or paragraphs from the interview text, from which open codes were extracted. After this, the main classes and themes were abstracted, with updates made after each interview. The scientific accuracy of the qualitative section was assessed using the four criteria of credibility, transferability, dependability and confirmability [17, 18]. The combined criteria were used to report qualitative studies (COREQ) (Additional file 2).

Table 1.

Demographic characteristics of participants in the study

Participants	Job		Workplace			Work experience	Education			Age
	Manager	Expert	Insurance of Tehran province	Insurance of Mazandaran Province	Insurance of Fars Province		PhD	MSc	B.C
P1		✓	✓			8	✓			35
P2	✓		✓			26	✓			52
P3		✓	✓			25	✓			54
P4	✓		✓			28	✓			53
P5	✓		✓			27	✓			54
P6		✓	✓			23	✓			52
P7	✓		✓			28	✓			54
P8		✓		✓		25	✓			51
P9	✓			✓		29	✓			55
P10	✓			✓		27	✓			56
P11		✓		✓		22	✓			46
P12		✓		✓		26	✓			53
P13		✓		✓		21			✓	50
P14		✓			✓	24			✓	48
P15		✓			✓	23			✓	51
P16	✓				✓	25	✓			52
P17		✓			✓	22	✓			45
P18	✓				✓	27	✓			53
P19	✓				✓	23	✓			48
P20		✓		✓		25			✓	49
P21		✓	✓			8	✓			36
P22		✓	✓			25	✓			50

To prioritize potential solutions, we initially developed a survey in which participants evaluated 41 potential solutions against eight criteria. The criteria included health problem burden (0.2), effectiveness (0.2), cost (0.15), political acceptance (0.1), acceptability by providers (0.05), equity (0.1), time (0.05), and feasibility (0.15), based on a Likert scale ranging from very low to very high. Expert opinions and the Shannon entropy method were applied to measure the criteria. Following the completion of questionnaires by 12 participants in the first phase of the study, the simple additive weighting (SAW) method was ultimately employed to rank the solutions [19]. To this end, the decision matrix underwent linear scaling in its initial stage. Positive indicators were scaled using Eq. (1) and negative indicators using Eq. (2).

$$n_{\mathit{ij}}=\frac{a_{\mathit{ij}}}{\begin{array}{c}Max\left(a_{\mathit{ij}}\right)\\ t\end{array}}$$ 1

$$n_{\mathit{ij}}=\frac{\begin{array}{c}Min\left(a_{\mathit{ij}}\right)\\ t\end{array}}{a_{\mathit{ij}}}$$ 2

Next, we created a weighted matrix, displaying the importance coefficient of each option. The higher the coefficient, the more highly ranked the option becomes.

$$S_i=\sum _j{n}_{\mathit{ij}}·w_j$$

To adhere to ethical standards, in addition to receiving approval from the university's research deputy with the code IR. SBMU. SME. REC.1400.025, the study's aims were thoroughly explained to the participants. They were provided with assurances of confidentiality and were advised not to share or publish any recorded voices, which would be deleted at the end of the study.

Results

The participants were selected from among the managers, experts and policy makers of the basic insurance organizations in three provinces of Tehran, Mazandaran and Fars (Table 1).

The participants suggested feasible solutions within ten main themes: financing, leadership, human resources, structure, culture building, payment mechanism, information system, monitoring and control, function of insurance organizations and implementation. These themes are listed in order of priority in Table 2. The information system theme was considered the highest priority among the mentioned themes. Additionally, Table 3 presents the final weight of each sub-theme and the weight of all eight indicators with respect to that sub-theme. The tables also show the ranking of themes and sub-themes.

Table 2.

Prioritization of themes

Priority	Theme	Weight
1	Information system	0.924
2	Function Of Insurance Organizations	0.915
3	Structure	0.894
4	Financing	0.889
5	Monitoring and control	0.872
6	Performance	0.854
7	culture building	0.852
8	Human resource	0.844
9	Payment mechanism	0.805
10	Stewardship	0.796

Table 3.

Final weight of sub-themes (solutions)

Themes /weight	Sub-theme (solution)	Weight
Financing/0.889	Sustainable financing	0.901
	Allocation of financial credit to insurers	0.884
	Participation of all insurance funds in the program implementation	0.881
Stewardship/0.796	Management of conflicts of interest in the pharmaceutical industry	0.787
	Management of the conflict of interests of the specialist	0.839
	Selection of managers with a systems thinking perspective	0.899
	Continuity of policies after the change of governments	0.849
	Controlling the pressure of external factors	0.879
	Strengthening the link between evidence and policy	0.904
	Localization of policies based on regional characteristics	0.765
	Specifying the Program steward	0.884
	Publication of transparent management guidelines	0.866
	Creating more interaction between programme actors	0.934
	Determining the role of stakeholders	0.879
	The need to involve upstream institutions in policy development	0.880
Human Resource/ 0.844	Community based education	0.980
	Providing incentives to service providers	0.846
	Formation of family physician cooperatives	0.706
culture building /0.852	Community outreach and education	0.910
	Grant privileges to the recipients of the service	0.794
Information System/0.924	Integration of the information systems	0.909
	Providing suitable electronic infrastructure	0.940
Structure/0.894	Establishment of family physician organizations	0.894
Payment/0.805	Accurately determine physician capitation payments	0.882
	Separation of the salary of the health care worker from the physicians	0.881
	Pay to physician based on a combination of capitation and performance	0.807
	Adjusted capitation payment to family physician cooperatives	0.652
Monitoring & Control/0.872	Studying the effectiveness of program implementation in multiple versions	0.868
	Monitor the program with the right tools	0.935
	Joint supervision of insurance and the ministry of health	0.892
	Formation of non-governmental accreditation organization	0.791
Function Of Insurance Organizations/0.896	Playing the real role of insurance	0.915
	Delegation of authority to Insurance Organizations	0.876
Iimplementation/0.854	Decision on continuation of the programme	0.865
	Strengthening the sociological approach and two-way referral in the family physician	0.854
	Develop and implement the programme at national level	0.872
	Mandatory referral in the health system	0.819
	Availability of a physicians	0.928
	Eliminate fee for service payments for family physician services	0.657
	Increase the depth of service coverage	0.882
	Developing an action plan to implement the program	0.944

The table highlights that the most significant priorities in the ten areas are sustainable financing solutions in the financing area, increased interaction among program stakeholders in the leadership area, community-focused medical education in the human resources area, raising awareness among community in the cultural area, expert assessment of per capita in the payment area, effective program monitoring and control with suitable tools, demonstrating the actual function of insurance organizations in the insurance function area, and developing an operational program implementation plan. Among the 41 existing solutions (sub-themes), community-oriented medical education was deemed the highest priority. As for the structure area, there was only one sub-theme available, which was the creation of family physician organizations, thus, making prioritization infeasible.

Also In Table 4 provide the prioritizing each solution regarding each criterion and also overall ranking.

Table 4.

Subtheme weight per criterion

Subtheme weight per criterion								Weight of sub-theme	Sub-theme	Theme
										Weight of theme
Feasibility	Time	Equity	Acceptability by providers	Political acceptance	Cost	Effectiveness	Health problem burden
0.935	0.812	0.941	0.969	0.774	0.911	0.942	0.971	0.901	Sustainable financing	Financing 0.889
0.935	0.718	0.882	0.909	0.709	0.882	0.875	0.971	0.884	Allocation of financial credit to insurers
0.870	0.781	0.941	0.909	0.741	0.882	0.914	0.914	0.881	Participation of all insurance funds in the program implementation
0.806	0.843	0.823	0.787	0.741	0.647	0.828	0.828	0.787	Management of conflicts of interest in the pharmaceutical industry	Stewardship 0.796
0.806	0.843	0.823	0.696	0.709	0.852	0.885	0.914	0.839	Management of the conflict of interests of the specialist
0.903	0.781	0.970	0.939	0.645	0.852	0.942	1	0.899	Selection of managers with a systems thinking perspective
0.870	0.937	0.941	1	0.451	0.852	0.857	0.914	0.849	Continuity of policies after the change of governments
0.838	0.937	0.941	0.939	0.741	0.911	0.885	0.885	0.879	Controlling the pressure of external factors
0.870	0.843	0.911	0.879	0.838	0.941	0.914	0.942	0.904	Strengthening the link between evidence and policy
0.838	0.875	0.705	0.727	0.741	0.823	0.657	0.8	0.765	Localization of policies based on regional characteristics
0.935	0.812	0.882	0.969	0.741	0.882	0.885	0.914	0.884	Specifying the Program steward
0.903	0.75	0.852	0.878	0.806	0.823	0.914	0.885	0.866	Publication of transparent management guidelines
0.903	0.875	0.941	0.939	1	0.911	0.942	0.942	0.934	Creating more interaction between programme actors
0.967	0.875	0.852	0.878	0.806	0.882	0.885	0.857	0.879	Determining the role of stakeholders
0.838	0.906	0.941	0.848	0.677	0.970	0.942	0.857	0.880	The need to involve upstream institutions in policy development
1	1	0.970	1	0.838	1	1	1	0.980	Community based education	Human Resource 0.844
0.870	0.843	0.882	0.939	0.709	0.794	0.857	0.885	0.846	Providing incentives to service providers
0.645	0.718	0.617	0.757	0.709	0.705	0.714	0.771	0.706	Formation of family physician cooperatives
0.935	0.968	0.911	0.909	0.870	0.882	0.885	0.942	0.910	Community outreach and education	culture building 0.852
0.838	0.781	0.764	0.787	0.774	0.735	0.8	0.828	0.794	Grant privileges to the recipients of the service
0.870	0.937	0.941	1	0.612	0.882	0.971	1	0.909	Integration of the information systems	Information System 0.924
1	0.906	0.970	1	0.580	0.970	0.971	1	0.940	Providing suitable electronic infrastructure
0.942	0.781	0.882	0.909	0.903	0.941	0.885	0.885	0.894	Establishment of family physician organizations	Structure 0.894
0.838	0.718	0.941	0.909	0.806	0.823	0.942	0.942	0.882	Accurately determine physician capitation payments	Payment 0.805
0.967	0.75	0.970	0.969	0.612	0.882	0.857	0.942	0.881	Separation of the salary of the health care worker from the physicians
0.741	0.718	0.911	0.939	0.741	0.735	0.885	0.8	0.807	Pay to physician based on a combination of capitation and performance
0.741	0.562	0.588	0.666	0.677	0.676	0.628	0.628	0.652	Adjusted capitation payment to family physician cooperatives
0.903	0.843	0.911	0.909	0.838	0.735	0.885	0.914	0.868	Studying the effectiveness of program implementation in multiple versions	Monitoring & Control 0.872
0.935	0.937	0.941	0.878	0.903	0.911	0.942	0.971	0.935	Monitor the program with the right tools
0.870	0.906	0.852	0.787	1	0.882	0.885	0.914	0.892	Joint supervision of insurance and the ministry of health
0.903	0.812	0.852	0.636	0.741	0.735	0.771	0.8	0.791	Formation of non-governmental accreditation organization
1	0.812	0.941	0.696	0.709	0.911	0.942	1	0.915	Playing the real role of insurance	Function Of Insurance Organizations 0.896
0.967	0.875	0.970	0.727	0.709	0.823	0.885	0.914	0.876	Delegation of authority to insurance companies
0.935	0.843	0.941	0.818	0.612	0.882	0.857	0.914	0.865	Decision on continuation of the programme	Iimplementation 0.854
0.870	0.843	0.882	0.848	0.741	0.823	0.885	0.857	0.854	Strengthening the sociological approach and two-way referral in the family physician
0.838	0.906	0.941	0.909	0.870	0.764	0.885	0.914	0.872	Develop and implement the programme at national level
0.741	0.781	0.794	0.767	0.645	0.911	0.828	0.914	0.819	Mandatory referral in the health system
0.870	0.906	1	0.909	1	0.941	0.914	0.914	0.928	Availability of a physicians
0.709	0.5	0.558	0.484	0.709	0.558	0.714	0.742	0.657	Eliminate fee for service payments for family physician services
0.838	0.906	0.911	0.909	0.935	0.911	0.857	0.866	0.882	Increase the depth of service coverage
1	0.935	0.941	0.969	0.967	0.911	0.914	0.942	0.944	Developing an action plan to implement the program

Financing

The research participants put forward three possible solutions to address financing issues in the area, namely sustainable financing, crediting Insurance Organizations, and consolidating insurance funds. Most participants emphasized sustainable financing and said: “A separate and stable credit line should be considered for the program (P12, P9, P7, P20, and P14)”.

Stewardship

The interviewees identified several solutions in the leadership area, such as reforming the conflict of interest of pharmaceutical companies and specialists, selecting managers with systemic thinking and vision, ensuring continuity of policies after changing governments, controlling external pressures, localising programmes, defining the responsible party, developing and implementing simple laws, emphasising the need for interaction among programme stakeholders, determining stakeholder roles, and incorporating upstream institutions. After prioritisation, the analysis identified that enhancing interaction between program stakeholders within the leadership domain was of utmost importance. Many participants stated that it is necessary to have interaction among stakeholders of the program and involvement of upstream institutions for the improved implementation of the program. “All program stakeholders should gather and communicate with one another (P15).” “It is necessary for teamwork; the Ministry of Health must meet this responsibility.” “Not all effective health measures have been utilized in family medicine. The governorate and politicians have not fulfilled their duty to inform the public. It is important to clarify to people that doctors should be present at their workplace unless there is a valid reason for their absence (P12)”.

Human resources

The participants discussed potential solutions in the human resources field. Some suggested community-based medical training as a solution to the qualitative scarcity of human resources. Others proposed that providing incentives could also alleviate the shortage to some extent. Among these two options, community-based medical education held a significant priority in this theme and all sub-themes. “Our doctors haven't received training for this programme. They have only received training for treatment. It's important for both patients and doctors to receive training on this matter.” “Our university education system needs to prioritise health. It is currently treatment-focused, unsuitable, and not in line with the structure of the family Physician program (P9).”

Structure

Several interviewees mentioned the necessity of establishing an organization that corresponds to the structure of family Physician within insurance firms and medical universities."At least one official should be designated as the Health Deputy for this programme. The same applies to insurance organisations. A Family Physician Office needs to be established. This office should be established at the headquarters (P10)."

Culture building

Many managers mentioned raising awareness and incentivizing those who receive services as potential solutions to cultural problems. However, after prioritizing these approaches, raising awareness had a higher priority than providing incentives"The health system must prioritize culture-building, which has not been adequately addressed for both service providers and patients. Without proper attention to this aspect, resistance may arise (P7)." "We need to promote the idea of having a family doctor through radio and television, so that people understand it is beneficial for them. This will encourage patients and doctors to enroll in the program willingly. After a certain time, we can declare that the only option available is to have a family doctor (P14)”.

Information system

Some participants suggested solutions, including the provision of suitable electronic infrastructure and system integration for information systems. After prioritizing the measures, electronic infrastructure received greater emphasis than integrating systems. Numerous participants emphasized the necessity of providing a suitable digital platform for data collection, given the vital role of data in evidence-based decision-making. Electronic infrastructure should be given to gather handwritten orders and papers. Furthermore, a platform for electronic prescriptions, which has been provided, should also be given. The system should be easily accessible from different parts. In case a physician wants to take a leave, they should use this system instead of calling or bringing a paper sheet. If referral is needed, it should also be done through this system. Even a GP can schedule a consultation with a specialist within this system. It offers the optimal solution (P14).”

Payment mechanism

Among the proposed solutions in the payment field, the participants suggested expert Accurately determine physician capitation payments, separation of healthcare salary from physicians, payment based on a combination of per capita and performance, and adjusted per capita payment to family physician cooperatives. The prioritization of these solutions resulted in expert determination of per capita being given the highest priority. Some participants suggested that the “per capita amount should undergo a thorough analysis and determination. This means that a reasonable amount of per capita needs to be considered in light of the program's goals and expectationsThe amount you pay for healthcare should reflect the level of service you receive from your family physician. Start by considering what you need from your physicians and the services you want. It's important to ensure that family physicians are properly compensated for providing preventative healthcare services. The more you pay, the more services you can expect. Sometimes you may not want them to act as gatekeepers and instead view them as an aspect of healthcare, which is a separate matter (P10)”.

Monitoring and control

The solutions proposed by experts in this area involved investigating the various versions of program implementation to assess their effectiveness. They also recommended monitoring programs using appropriate tools, establishing joint supervision between insurance providers and the Ministry of Health, and creating an independent accreditation organization. Among these options, the highest priority was given to program monitoring with suitable tools for monitoring and control. Abbreviations for technical terms will be explained upon their first use. "We can't continue with the usual way of checking and reviewing. It needs a software that hasn't been created yet. I have 600 family physicians. How can I make sure they're at work? Before, physicians just visited patients but now they have to constantly work as healthcare providers with a physician present." "We use suitable tools to oversee these usual services, even though we are not yet perfect (P8)."

Function of insurance organizations

The participants recommended that insurances play a genuine role, with authority delegated to them. Following prioritisation, the findings revealed that insurances playing a genuine role took precedence over delegating authority to them. “An organization with the concept of insurance and acting as an agent of the insurer who assumes the role of the buyer is essential (P2).”

Implementation

The participants recommended various solutions for the program's implementation process. These include determining the program's fate, strengthening the community-oriented approach, introducing bilateral referrals in family medicine, Develop and implement the programme at national level, creating and implementing a unified version nationwide, mandating referrals, ensuring physicians availability, Eliminate fee for service payments for family physician services, expanding service coverage, and devising an operational plan for the program's implementation. After careful prioritisation, the conception of an operational plan was deemed as having the utmost priority amongst the available solutions in this area. The Ministry of Health does not say what it wants. We also propose a package that it does not accept its price. It should specify what it wants. If a decision is made, a deadline should be set.

“The Ministry of Health doesn't specify its requirements. It doesn't agree with the packages we propose or the price of the packages we offer. He needs to be clearer about his requirements (P12) ”. “If a decision is reached, it should be given a deadline (P15).”

The themes of each area were ranked according to priority in Table 3, comprising a total of 41 solutions. As per the participants' feedback from this study, community-based physician training was given the highest priority with a final weight of 0.98. Table 4 exhibits all 41 solutions ordered by ranking, numbered from one to forty-two. Table 5. Priority of solutions in order (from highest to lowest).

Table 5.

Priority of solutions in order (from highest to lowest)

Solution	Weight	Priority
Community based education	0.980	1
Developing an action plan to implement the program	0.944	2
Providing electronic infrastructure	0.940	3
Monitor the program with the right tools	0.935	4
Creating more interaction between programme actors	0.934	5
Availability of a physicians	0.928	6
Playing the real role of insurance	0.915	7
Community outreach and education	0.910	8
Integration of the information systems	0.909	9
Strengthening the link between evidence and policy	0.904	10
Sustainable financing	0.901	11
Selection of managers with a systems thinking perspective	0.899	12
Establishment of family physician organizations	0.894	13
Joint supervision of insurance and the Ministry of Health	0.892	14
Allocation of financial credit to insurers	0.884	15
Specifying the Program steward	0.884	16
Increase the depth of service coverage	0.882	17
Accurately determine physician capitation payments	0.882	18
Separation of the salary of the health care worker from the physician	0.881	19
Participation of all insurance funds in the program implementation	0.881	20
The need to involve upstream institutions in policy development	0.880	21
Determining the role of stakeholders	0.879	22
Controlling the pressure of external factors	0.879	23
Delegation of authority to Insurance Organizations	0.876	24
Studying the effectiveness of the program in multiple versions	0.868	25
Develop and implement the programme at national level	0.866	26
Publication of transparent management guidelines	0.866	27
Decision on continuation of the programme	0.865	28
Strengthening the sociological approach and bilateral referral	0.854	29
Continuity of policies after the change of governments	0.849	30
Providing incentives to service providers	0.846	31
Management of the conflict of interests of the specialist	0.839	32
Mandatory referral in the health system	0.819	33
Pay based on performance and per capita integration	0.807	34
Grant privileges to the recipients of the service	0.794	35
Formation of non-governmental accreditation organization	0.791	36
Management of conflicts of interest in the pharmaceutical industry	0.787	37
Localization of policies based on regional characteristics	0.765	38
Formation of family physician cooperatives	0.706	39
Eliminate fee for service payments for family physician services	0.657	40
Adjusted capitation payment to physician cooperatives	0.652	41

Discussion

The study results delineate a hierarchy of solution priorities, structured around central themes and their respective sub-themes. The sequence of importance is as follows: 1. Information Systems: Foremost importance is placed on the sub-theme of crafting an adequate electronic infrastructure, 2. The Function of insurance organizations: The sub-theme of actualizing the fundamental role of insurance is prioritized, 3. Organizational Structure: Priority is given to the sub-theme concerning the formation of family physician entities, 4. Financial: Emphasis is placed on the sub-theme related to enduring financial stability, 5.Monitoring & Control: The sub-theme of employing the correct tools for program monitoring is highlighted, 6. Implementation of Plan: The development of a strategic action plan for program implementation is prioritized, 7. Cultural Integration: The sub-theme of enhancing community engagement and education is underscored, 8. Human Resource Development: The sub-theme of Community based education is emphasized, 9. Payment mechanism: The sub-theme of precise calculation of physician capitation payments is given precedence, 10. Stewardship: The sub-theme of fostering greater interaction among program participants is prioritized.

The research identified, in order of importance, the most pertinent solutions to the obstacles to the implementation of the Iranian Urban Family Physician Initiative, which may enhance the achievement of the program's goals and the prospect of its nationwide implementation. Numerous respondents suggested that the program's implementation necessitates sustainable and considerable financial provisions. Paragraph 10 of the General Health Policies has highlighted the crucial matter of stable funding in the healthcare system. As per a report by the Research Centre of the Parliament, a sum of 1,399 billion Tomans has been allocated for the completion of the "Electronic Health Record Programme", management of the referral system, and implementation of the Family Physician Programme in the Budget Bill of 1401. It is noteworthy that 12,500 billion Rials have been allotted through subsidies. It appears that for implementing costly programs, including the family physician program, sustainable funding is a requirement to ensure continuity and widespread availability. Akbari et al.'s [20] study identified financing as one of the principal benefits of consolidating insurance funds. Mohtarpour et al. have highlighted the importance of securing sustainable funding to support the program's implementation in their research [21]. According to program financiers who participated in the study, ensuring the longevity, continuity, and expansion of the program requires a sustainable financial resource.

It appears that the program's successful implementation is reliant on stakeholders' participation and cooperation and their proper identification and fulfilment of roles. Additionally, enacting and adhering to relevant laws are essential for the proper implementation of any program. Damari et al. [4] conducted a study assessing the governance of the urban family physician program and referral system in Fars and Mazandaran provinces. The study showed that there is ambiguity surrounding the responsibility for implementing the program and weaknesses in both intersectoral and intrasectoral participation. Mohammadi Bolbolan Abad et al. [22] identified governance challenges, including weaknesses in policy-making, law and guideline formulation, monitoring & control, intersectoral and intrasectoral coordination, as well as insurance organization performance in the family physician program and referral system. The authors provide sub-themes on these challenges.

Training is crucial for them to act as family physicians and health gatekeepers, and to employ a sociological approach. Without this, the programme's objectives and outcomes will be unfavourable. According to the participants, the quantity of physicians provided is not the only factor. Kabir et al. suggest that preparing the health team's members to execute tasks specified within the basic health service package is paramount. Efficient provision of services within this framework relies on the expertise, proficiency and productive contribution of the family medicine workforce. Specialized teams situated in regional health centres, coupled with the resources of health education centres and educational groups within academic faculties, can provide favourable scientific backing to enhance awareness and the abilities of program implementers within this sphere [14].

Several participants suggested that, in line with the program's objectives, there should be establishments in both insurance organizations and medical science universities. This would entrust the responsibility of following up on matters related to program implementation to such structures, highlighting the significance of the matter. There were no reported cases addressing this theme in comparable studies.

It is worth noting that the effective implementation of preventive interventions in conjunction with the family medicine programme and referral chain can be substantially impacted by community participation and cooperation [23]. It appears that the success of the family medicine programme has been recognised by the community who are important stakeholders in the programme. However, if these Community are unaware of the programme, their resistance may pose a problem, as suggested by the participants. Therefore, it is paramount to culturally embed and justify the programme to increase its chances of success. Alaei and colleagues suggest in their study that the successful implementation of the program requires investment in both the health system and people. Therefore, it is recommended to promote the use of the referral system culture and strengthen the position of family physicians by utilizing media capacities and methods based on local cultures, as well as long-term planning for explaining the referral system using educational capacity [24]. Kabir and his colleagues suggest that the full potential of media should be utilized for culturalization and public education to enhance public engagement and provide relevant context [14]. Shams et all also pointed out the weakness of the cultural foundation in the implementation of rural family physician with more executive experience in implementation [25].

Some participants suggested establishing an organization in Insurance Organizations and medical universities to ensure that matters related to program implementation are followed up responsibly. This would demonstrate the importance of the subject, in line with the program's objectives. No similar studies have identified such a framework. It is worth noting that the successful implementation of preventive interventions through the family medicine programme and referral chain may strongly rely on community participation and cooperation [23]. It appears that the community, who constitute a significant stakeholder group for the family medicine program, perceive its results. However, the participants suggest that if the community are not made aware of the program, they may resist its implementation. Alaei et al. recommend simultaneous investment in both the health system and the general population for successful program implementation. To promote the culture of utilizing the referral system and strengthen the position of family physicians, they suggest utilizing media capacities, employing methods aligned with local cultures, and implementing long-term planning to explain the referral system through educational capacity [24].

Kabir and colleagues state that maximising the potential of media professionals in culturalization and public education is a crucial approach to gaining public engagement and providing crucial context [14]. Fardid and associates also highlight the significance of media and advertising teasers as a valuable tool in promoting awareness [26]. It appears that information systems provide an essential source of data for making evidence-based decisions. Therefore, effective decision-making and enacting change at both micro and macro levels necessitates comprehensive and integrated information systems. These systems will enable policy makers to access accurate and comprehensive health information. Moreover, the researcher highlights that the priority of implementing the family medicine programme is logical when considering its dependence on the referral system's correct implementation and the exchange of information among the various referral levels through a health file. Demari et al. [4] also note in their study the crucial need to provide technical infrastructure for electronic records. In his research with Behzadifar and colleagues [27], the need for a comprehensive health information system to improve individuals' health has been highlighted. The participants suggest that accurately determining the per capita amount in line with inflation could help address the livelihood challenges faced by physicians and other healthcare professionals who provide frontline health services. The potential positive effects of implementing this solution extend beyond its immediate impact. Schweizer's research [28] highlights the payment mechanism as a factor in employee motivation, making it desirable for all. As such, this solution may boost staff morale, increasing productivity and job satisfaction.

The participants recognized the important role played by insurance organizations in executing the family physicians program. They stated that insurance's role goes beyond mere financial provision and that increasing the involvement of insurance would be a top priority to strengthen the program. Insurance organisations are discontented that they are relegated to the role of a mere ATM and are not given an active say in shaping policies or enforcing regulations. They hope to be involved in a buyer's capacity, with the requisite empowerment and independence to implement programmes. Of course, as previously mentioned, given that the study's participants were mostly chosen from insurance organizations, the prominence of the theme surrounding insurance organizations' operations appears somewhat justified.

A thorough assessment of the programme should be conducted with the use of scientific and standard tools. An evaluation of its general areas ought to be made, followed by the identification of performance indicators. This is essential to promote accountability, monitor performance, and modify behaviour [29].

Physicians and hospitals in America are monitored and assessed by governmental, regulatory, and non-governmental organizations at federal and state levels. Obtaining a new license is contingent on complying with initial standards, and licenses may be revoked for improper activity [30]. In Turkey, the performance evaluation of the family medicine team is conducted every six months and randomly every month to ensure the achievement of goals and provision of quality services. In case of poor performance, the contract is terminated [31]. Developing an operational plan for implementation was identified as the key priority relating to this topic. Before commencing and executing the programe, it is imperative to ensure that the plan devised is feasible. The subsequent steps should be outlined step-by-step once the goals are determined, and time is allocated for budgeting. The participants suggest that execution of the plan should follow a well-structured approach.

Limitations

Given that the study participants primarily consisted of managers and experts from insurance organizations, potential bias in the study results exists. Findings from similar studies involving non-insurance participants may yield different results.

Conclusion

The research team has identified a number of key actions that the Ministry of Health should undertake in order to enhance the urban family physician program in Iran. The following actions are recommended: It is recommended that the educational curriculum at universities be revised to align with community needs and values, with the objective of ensuring that physicians are trained with a community-oriented approach. It is recommended that a robust electronic infrastructure be provided to integrate various systems, thereby improving access to insurance organizations and facilitating efficient data aggregation. It is recommended that a substantial financial allocation be made to the program’s implementation, with the funds managed by insurance organizations to ensure effective utilization. Furthermore, it is proposed that specific authorities be delegated to insurance organizations to foster alignment with program objectives and garner their support. Furthermore, it is proposed that advanced monitoring tools, in addition to checklists and traditional methods, be employed to evaluate the program and health team performance, with a particular focus on family physicians. It is recommended that a standardized operational plan be developed and implemented, which reflects the cultural and socio-economic nuances of the country in question. Furthermore, it is of the utmost importance to implement mandatory referral processes.

It is also important to note that the research team believes that the parliament and judiciary have a critical role to play in securing the engagement and collaboration of pertinent organizations. The implementation of these measures is projected to significantly enhance the quality and efficacy of the urban family physician program in Iran.

Abbreviation

FP

Family Physician

Authors’ contributions

FM is a graduate student in the field of Health care managment, who has been actively engaged in each step in the research process (Concepts, Design, Literature search, Data acquisition, Data analysis, Statistical analysis, Manuscript preparation, Manuscript editing and Manuscript review). LS was the study guide and participated in the entire study process. RM participated in data analysis and writing the Manuscript. TN editing and revised the manuscript.

Funding

The study was funded by Shahid behesgti universiy of medical sciences (28641) AND Social Security Research Institute (SSOR.IR).

Data availability

The data that support this study will be shared upon reasonable request to the corresponding author.

Declarations

Ethics approval and consent to participate

The research purpose and methodology were reviewed and approved by the Internal Research Ethics Committee of Shahid Beheshti University of Medical Sciences (IR.SBMU.SME.REC.1400.025). Informed consent was obtained from all the participants. The informants gave written informed consent to participate after receiving written and verbal information about the study. Participation was voluntary, and the participants could withdraw at any time before publication without consequences. The study was conducted in accordance to relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.