Table 1. Challenges in the implementation of the pay-for-performance system in Iran's family physician program.

Main Themes	Sub-Themes	Related Codes
Workload	Heavy workload of family physicians	Broadness of duties Large number of covered people
	Lack of management skills in family physicians	Lack of knowledge and skills related to leadership Lack of knowledge and skills related to quality Lack of knowledge and skills related to teamwork
Training	Lack of knowledge and skills related to preventive and social medicine in family physicians	Medical students neglecting public health courses Lack of newcomer and in-service trainings Weakness of family physicians, especially in promotional and preventive affairs Physician's activity in family physician team limited to the conventional therapeutic approach Weakness of family physicians' attitude towards the nature and activities of this program
	Lack of awareness among people about the nature and importance of family physicians	Poor education by the MOHME and mass media about the family physician program Public failure to follow the referral system Low public trust in the expertise and ability of family physicians Use of physicians with little experience as a family physician
Program cultivation	Self-underestimation of status and importance among family physicians	Giving little importance to family physicians relative to clinical specialties View among family physicians that the job is a temporary one that they will leave soon
	Weak intra/extra-collaboration with family physician team	Poor collaboration of institutions outside the health sector with family physician team Lack of feedback about referred patients by specialists to the family physicians
	Low PHC budget	Low PHC budget relative to hospital services Low wages for family physicians relative to specialists
Payment	Lack of proper infrastructure for instituting P4P	Insufficient infrastructure for performance-based payment system Clinical and treatment views of the managers in charge of paying family physicians Individual-centeredness of payments Lack of competition among family physicians
Assessment and monitoring	Lack of criteria and scientific tools for qualitative assessment of the program	Lack of suitable criteria and assessment tools even for routine monitoring programs Lack of consideration of the conditions of different work environments and communities while monitoring Lack of attention to the multiplicity of functions and results in evaluations
	Lack of a well-defined mechanism for assessment	Government-owned monitoring and evaluation system and the lack of an independent entity for this task Lack of proper accreditation system in the field of PHC Overlooking doctor mistakes due to lack of physicians Lack of organization and discipline in monitoring and evaluation
	Lack of appropriate assessors	Lack of trained and experienced assessors Inappropriate treatment of assessors by family physicians and their teams
Information management	Poor information infrastructure	Weakness in software and hardware infrastructures Lack of proper health records, especially in electronic form
	Poor systemic management of production cycle and information flow	Poor management in the cycle of data collection and analysis as well as the production and flow of information Poor and incomplete filling of existing files by physicians Lack of appropriate databases related to health centers and their performances Lack of proper information exchange between institutions and different levels in the provision of services Neglecting the verification of documentations and reports provided by family physicians Non-correspondence of the data and information created in the system with the real needs Negligence of user-friendliness of the information provided for different users
Level of authority	Insufficient authority of family physicians	Inadequate authority of family physicians to establish intra/extra sectoral relationships Lack of sufficient supervisory power of family physicians over the health team and social workers Inadequate authority of physicians in the selection or modification of the health team members