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

Abstract 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


Introduction
According to the World Health Organization (WHO), nancing is one of the six building blocks of health care systems. 1,2It is also the main pillar among the 'necessary features of the national health system' and at the heart of its success. 3alth system nance is a long-standing challenge in Iran, with a high rate of out-ofpocket payments. 4,5e distribution of health expenditure in Iran in 2008 was as follows: 24.9% paid by the general governmental budget, 20% paid by social health insurance, 52.7% paid out of pocket and 2.4% paid by other private sources. 6In the same year, urban and rural households paid in average 6.4% and 6.35% of their total expenditure on health services, respectively. 7While social protection measures and insurances reduce the pressure on household welfare, the inadequate targeting of bene ts and the lack of correlation of their value with in ation have decreased their impact over time. 7Hajizadeh and Nghiem suggested that a single universal health insurance plan can save households from catastrophic health spending despite di erent employment status. 8an experienced di erent reforms in its health care system to increase accessibility to health services.e country implemented the family physician programme (FPP) nearly two decades ago 9 as a major health reform. 10initial plan was to establish the programme in four provinces in Iran and then expand it to other provinces.At the beginning of the implementation process, some modest achievements were reported 11 ; however, the FPP was not expanded owing to multiple challenges.
REVIEW REVIEW Among the challenges in the FPP in Iran are nancial and insurance issues. 12,13e proximal sources of programme funding are taxation and insurance premiums. 3FPP in Iran was supposed to be sourced through the governmental budget.e required budget 'was foreseen and approved in the budget law'.However, the allocation of the budget was a matter of concern.14 While the successful implementation of the FPP closely relied on insurance organisations, studies have shown that insurance companies were not ready to embrace the FPP owing to hasty initiation of the programme without addressing the required infrastructures.15 is scenario worsened because of the unsatisfactory operational history of insurance organisations, such as their long-overdue debts to health care providers.16 e health system and FPP function in a rapidly changing social and economic environment, and successful expansion of the programme requires a detailed analysis of its multiple major challenges, including the crucial aspect of its funding system.17,18 Since the introduction of the FPP, many studies have evaluated the programme from various dimensions, including its nancial aspect.
is study aimed to synthesise data from these studies via a systematic review to obtain comprehensive results.In particular, this systematic review was undertaken to identify the main challenges in the FPP relative to its nancing.

Methods
e study protocol was developed by the authors.
e methodology for publication selection and retrieval as well as data extraction and synthesis is described below.

Eligibility criteria
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 related to nancing of the FPP were included.Conversely, grey literature, quantitative studies, systematic reviews, commentaries, editorials, case reports, cross-sectional studies and studies published in languages other than English or Persian were excluded.
scholarly databases (Google Scholar and PubMed) and Persian databases (Iran Medex, Magiran, Irandoc and SID) were searched.In addition, the references of the selected articles were manually searched to nd additional relevant studies.

Search strategy
e search strategy was de ned based on keywords and the search syntax, which was rst de ned for the PubMed database and then revised based on each database's speci c framework of search method.e following keywords were used in both English and Persian: 'family physician', 'family physician care program', 'general practice', 'general medicine', 'general practitioner', 'general physician', 'insurance', ' nance', 'budget', 'fund', 'coverage', 'tari s', 'salary', 'wage', 'payment', 'per capita payment', 'performance-based payment' and 'Iran'.ese keywords were employed individually and in combination using the Boolean operators 'AND' and 'OR'.

Selection process
Based on the title and abstract of the articles, two reviewers independently evaluated the articles returned by the search in accordance with the inclusion criteria.Duplicate articles were removed at this stage.e studies were classi ed into three categories: 'excluded', 'included' or 'probable'.
e reviewers then evaluated the full text of the articles categorised as 'probable' and re-assigned them to either 'included' or 'excluded'.e lists generated by the reviewers were compared, and articles for which both reviewers agreed on categorisation were either excluded or included.When there was disagreement between the reviewers' assigned category of articles, the disputed articles were either included or excluded based on the evaluation by a third reviewer.

Data collection process
All selected articles were carefully studied, and the following data were extracted: title, authors, year of publication, name of the journal, design, participants, instruments, settings, variables, strengths and weaknesses.
For the nal review, all selected articles were carefully studied.After the full-text review, studies that lacked the aforementioned data to be extracted using the SPIDER technique were excluded from the analysis.

Data items
Challenges related to the insurance and nancial aspects of the FPP in Iran were the data items in this study.

Risk of bias assessment
Two independent reviewers conducted the eligibility and quality assessments and data extraction and sought the opinion of a third reviewer in cases of a di erence in opinion.
A methodologist checked the validity of the studies in accordance with the international guidelines for reporting of research, such as the Consolidated Criteria for Reporting Qualitative Studies.Published articles with low validity were excluded from the study.

Data synthesis
A thematic synthesis method was used to synthesise qualitative data from the included studies.
e synthesis process consisted of three interconnected stages.Multiple readings of the studies were conducted to ensure comprehensive coverage of views from the studies.First, the primary study ndings were coded line by line.Second, the codes were organised into categories that were related, leading to the development of descriptive themes.ird, analytical themes were extracted from the categorised codes.Di erences and similarities were examined, leading to the creation of a thematic structure by grouping emerging concepts.e nal stage yielded six detailed analytical themes.

Study selection
A total of 491 articles were retrieved from the search strategy, including 488 from the database search and three from the manual search.Of the 491 retrieved articles, 441 were excluded: 22 owing to duplication and 419 owing to irrelevance to the research strategy.Fifty studies met the inclusion criteria after screening of the titles and abstracts.After the full-text review, 29 studies were excluded owing to either a poor methodology design or a lack of data relevant to the research questions.Ultimately, a total of 11 eligible empirical studies were included in the present review (Figure 1).

Study characteristics
Table 1 shows the characteristics of the 11 included studies.All 11 studies used qualitative methods; the data were collected via interviews and focus group discussions.A total of 277 interviews and 29 focus group discussions were conducted in these studies.e participants included family physicians and other specialists, policy-makers, managers, nonphysician health professionals such as midwives and Behvarz (community health workers) and patients.Individuals from the Ministry of Health, health insurance organisations, management and planning organisations in Iran, the Iran Medical Council, medical universities and health research centres as well as social physicians and researchers in the eld of family medicine were also among the participants.
Six of the eleven studies investigated the urban FPP; two studies, the rural FPP; and three studies, both urban and rural FPPs.
readiness of the current health insurance system to embrace a great health system reform such as the FPP Unsatisfactory health insurance schemes in the past Long-term liabilities of health schemes to health care providers Delayed reimbursements by health insurances to family physicians Not ful lling insurance obligation regarding the FPP Lack of pooled fund and fragmented health insurance system Lack of a public insurance scheme No rational medical tari s based on the relative value of health services Inadequate nancial resources, underestimation of the required funds for the plan, allocation of available nancial support by entities other than the responsible institutions and lack of clear and stable nancial resources for the programme Fardid et al. ( 2019) 20 Multiple insurance funds Delayed payments to family physicians Spending of the allocated budget for other purposes Mehrolhassani et al. (2021) 14 Di erent insurance organisations and policies (di erent policies in health care and social security insurances and di erent insurances, such as oil industry or banks) e FPP in other countries has either followed the national health system or integrated insurance funds, but Iran has followed neither.Coordination between family physicians and insurance companies was later facilitated at provincial and local levels, so physicians began accepting their insurance cover.Payment and service purchase system: 'per capita 1 ' payment to family physicians and their teams versus 'single payment' for levels 2 and 3 2 Long delay (years) in payment of the approved budget (one of the reasons was the change in ministers and governments over the years) Some governments did not have a plan to allocate the budget to the FPP, so it was postponed.Dehnavieh et al. (2015) 15 Initiating the FPP before integrating the insurance schemes Lack of backup software for payment methods Unclear methods of payment Di erent payment methods for di erent suppliers Di culties in supervision owing to multiple payment methods Delayed payments (through an intermediary) Insu cient nancial resources Weak nancial processes Unpredictable economic conditions and sanctions imposed on Iran led to additional nancial problems for the FPP Injustice in funding Gharibi and Dadgar (2020) 21 Insu cient infrastructure for a performance-based payment system (value-based payment) Individual-centred payments instead of salaries Clinical and treatment approaches of managers who pay family physicians Lack of criteria and scienti c tools for qualitative assessment of the FPP for a performance-based payment (no direct relationship between performance indicators and the amount of e ort by physicians; di erent work conditions were not considered in the monitoring process; subjective monitoring was used instead of the objective type) A top-down monitoring approach instead of an educational approach, can enhance the FPP Lack of trained and experienced assessors for the FPP Low primary health care budget relative to hospital services (discouraging quali ed individuals from participating in the FPP, decreasing primary health care related interventions, and paying insu cient attention to the priority of prevention by health insurance systems) Clinical and treatment approaches of managers who pay family physicians Low wages of family physicians compared with those of specialists Clinical and treatment views of managers in charge of paying family physicians Mohammadi Bolbanabad et al. (2019) 22 Insurance deductibles Lack of a health-oriented vision of insurance Lack of a proper supervision structure in the health insurance organisation to monitor the FPP and rural insurance Delay in payment Insurance deductibles make it di cult to provide equipment for rural health service centres and houses.Delayed budgeting

Budget and funding
Nine studies addressed the challenges related to budgeting.ere was a lack of clear and stable nancial resources for the FPP.
[22][25][26][27] Financial resource allocation was a particular challenge, with lower budgets allotted to primary care services than to hospitalbased services.
is undermined the FPP by discouraging quali ed individuals from participating in the FPP, decreasing the implementation of PHC-related interventions and resulting in insu cient attention to the priority of prevention by the health insurance system. 21surance system e lack of a pooled fund and the fragmented health insurance system were the main challenges in this area. 14,16,20,23,26 FPP was implemented prior to integration with insurance; coordination between the FPP and insurance companies was later initiated at the provincial and local levels.14,15 ere was no coordination between multiple insurance policies and organisations and other payer sources, such as Iran Health Insurance, social security organisation, oil industry, banks and armed force.14,20,23,26 One study suggested merging social health insurance funds and establishing the Iran Health Insurance Organization as a proposed single fund.16 While the implementation of the FPP required public insurance, the studies showed that there is currently no e ective public insurance in the country.16 Tari s Tari s, the fees charged to patients for health care services, are another challenge encountered in the FPP.e lack of a national policy for tari s and the absence of rational medical tari s based on the relative value of health services, taking into account patients' ability to pay, were among the identi ed challenges.16,24,25 Payments Per capita payment to family physicians and their teams compared with single payment to specialists at the secondary and tertiary levels REVIEW of health care systems was another nancial challenge related to the payment methods. 14,23While performance-based payment was considered the most appropriate payment method for the FPP, there was insu cient infrastructure to implement such method in Iran.21 e population upon which the per capita payment was based for physicians was not well de ned, and the per capita payment amounts were low, presenting additional challenges in this area.24 Contrary to the intent of the FPP, a curative rather than a preventative focus by managers who pay family physicians and a similar lack of a population health-oriented vision by insurance organisations led to the employment of exclusively treatment-focussed measures in determining payments.[21][22][23][24] Delayed reimbursements by health insurances to family physicians and their teams, unclear methods of payment and lack of a backup software for methods of payment were among the insurance and nancial challenges noted.It was unclear to family physicians when or how much they will receive for the provided services, further discouraging participation in the programme.15,16,20,[22][23][24]26,27 Financial accountability Another challenge related to FPP nancing was inadequate oversight.
ere was no adequate supervisory structure within health insurance organisations for monitoring the FPP and rural insurance payments 22 ; the existence of multiple payment methods greatly complicated the task of oversight. 15e was a lack of trained and experienced assessors in the programme: Inspectors did not have the required expertise to assess the performance of family physicians.ere was no provision for funding of inspections in the programme. 21,23,24,26iteria and scienti c tools for qualitative assessment of the FPP for performance-based payment were lacking.
ere were no valid and reliable checklists for FPP assessment; in the absence of de ned measures, monitoring was conducted subjectively. 21,24Di erences in local conditions such as available resources or burden of a disease in a population were not taken into consideration during the monitoring process.
Using top-down and investigative-like approaches for monitoring instead of a collegial approach for enhancing the FPP was another challenge encountered.e approach was perceived as punitive rather than constructive.Monitoring by insurance organisations was conducted to determine the salary of individual family physicians, not to assess the achievement of the broader goals of the FPP. 21,23availability of inspectors during relevant times was de cient.Insurance o ces were closed in the afternoon, so family physicians were not monitored during afternoon hours, during which time most of the work is done.23 Inequity Discrimination was another challenge noted.Di erences in reimbursement sets between urban and rural family physicians, disparate salaries of members of family physician teams, lower wages for family physicians than for other physicians and discrimination in access to physician care between those insured by social security and health insurance organisations and those insured by other organisations were among the identi ed problems.21,23,24,26 e absence of incentive payments resulted in low motivation for specialists to participate in the FPP.24,26
In general, the Iran health system experiences many challenges regarding funding and nance. 32,33Moghaddam et al. reported inadequate overall and public nances, unsustainable resources and lack of cohesion in stewardship of nancing systems as some of the identi ed challenges. 33Adding the FPP imposed more challenges to the existing challenges of an already problematic system.e FPP in other countries has either employed a publicly funded national health service or incorporated private insurance funds, but Iran has followed neither. 14One of the reasons identi ed for the insu cient budget in Iran was the unpredictable economic conditions and nancial sanctions in the country. 15Further, transitions of governments resulted in inconsistent funding for the FPP, as some administrations did not intend to fund the programme. 14surance in Iran is fragmented, including multiple policies, lack of coordination among insurance organisations and lack of a public insurance scheme.
is challenge has long been recognised.Bazyar et al. reported that in Iran, multiple health insurance funds exist, without adequate provisions for transfer or redistribution of cross-subsidy among them. 34ultiple risk pools resulted in inequitable bene ts, ine ciency, low nancial protection for insured persons, high coinsurance rates, duplication in insurance coverage, discriminated bene t package of public health insurance schemes, underfunding and severe nancial shortages of public funds, and lack of transparency and reliable data.A lack of a profound vision in medical insurance and insurance funds with di erent methods of calculating premiums and collecting revenues was reported by Moghaddam et al. 33 Fragmentation was also noted in the leadership and management of the FPP.e Ministry of Health and Medical Education is the main policy-maker and is responsible for providing health care services, while the Ministry of Co-Operatives, Labor, and Social Welfare supervises the various public insurance schemes. 35se ministries do not commonly work e ectively together to achieve their mutual goal of health for the public.is review also found systematic and nonsystematic challenges in the payment system.
e payment system for the FPP is per capita and not performance-based.Conversely, the single-payment system is used for secondary and tertiary care levels.Herein, unclear methods of payment because of inadequate criteria for per capita payment, individualcentred payments instead of salary payment, insu cient infrastructure for a performancebased payment system, and lack of backup software for methods of payment were among the main challenges noted.Pay-forperformance schemes have been introduced in some countries to improve the quality of care provided. 37,38is approach also has a positive impact on decreasing induced demand and costs. 3 per capita payment method has been considered a source of con ict of interest between family physicians and specialists at the secondary care level, who receive performance-based payments.3 Delayed reimbursements by health insurances to family physicians were also mentioned as one of the challenges in the payment system herein.Some studies mentioned that payment through an intermediary could be one of the causes of delayed reimbursements.15,16,20,22,24,26,27 Further, untargeted health sector resources towards low-income deciles have long been a challenge in nancial and payment systems in the Iran health system.33 Supervision of the nance and payment system was another challenge.
e lack of trained and experienced inspectors with the required expertise to evaluate the FPP, lack of criteria and scienti c tools (e.g. a valid and reliable checklist for FPP assessment), and performance-based payment as well as diverse payment methods were some of the reasons behind challenges in supervision.Other challenges were the lack of proper supervision structure in health insurance organisations and a top-down monitoring approach instead of an educational approach, which can enhance the FPP.
Unfair and unjust payments as well as di erences in tari s set for urban and rural physicians, lower wages for family physicians than for other medical specialists such as paediatric or internal medicine physicians, and discrimination between those insured by social security and health insurance organisations and those insured by other organisations to access physicians were some of the issues related to unfair payment and budgeting system in this review.Many studies reported that inequity and unfairness in health nancing exist in the health system of the country, a ecting the FPP funding. 33,39,40oghaddam et al. showed that the nance system experiences inequity because of 'equal payment to services with di erent quality, di erent prices for a similar service, not to obey the public and private tari s'. 33ri s were also another challenging area noted in this review.Tari s do not account for the relative value of health services, in ation, educational level, or medical complexity.
ere is no national policy for tari and payment per capita instead of performance-based payment to health teams.Setting tari s for health care services has long REVIEW been recognised as a challenge.
is aspect has been sporadic and not evidence-based, resulting in disparity, lack of clarity, con ict of interest, and corruption. 36tential biases e present systematic review might have selection bias.In general, selection bias can arise when review authors unintentionally exclude relevant studies or include nonrelevant studies.To address this problem, two reviewers selected the studies in this review.

Conclusion
is study identi ed major challenges in di erent aspects of FPP nancing including budget and funding, insurance system, tari s, payments, supervision of nance, and inequity in the system.ese challenges should be addressed prior to any attempt to expand the programme across Iran.

Implications for practice
• A su cient, clear, and stable nancial resource for the FPP is recommended.• An integrated public insurance is suggested for the FPP.• A national policy for tari s that incorporates rational medical pricing, considering both the relative value of health services and patients' nancial capacity to pay, must be established.

Implications for research
Systematic research on the nancial aspects of the FPP, including its cost-e ectiveness, and the impact of any intervention on this programme is recommended.

Figure 1 .
Figure 1.Flowchart of the publication selection.

Table 1 .
Characteristics of the included studies.

Table 2 .
e insurance and nancial challenges in the Family Physician Program (FPP) of Iran based on systematic review of the publications

Table 2 . Continued Author (year) Insurance and nancial challenges
23edi et al. (2017)23Using a per capita model instead of a function-based model for payments to health care teams Lack of a health-oriented vision of insurance organisations Insurance inspectors do not have the expertise to assess the performance of physicians No training programme for insurance inspectors No wage speci ed for insurance inspectors monitoring the FPP No monitoring by insurance inspectors during afternoon hours Monitoring by insurance organisations was conducted to determine family physicians' salary, not to assess the progress towards the FPP goals.Unjust payment to members of family physician teams Di erence in tari s set for urban and rural physicians Delayed payment Multiple insurance funds and lack of coordination between them Discrimination between those insured by social security and health insurance organisations and those insured by other organisations to access physicians

Table 3 .
Insurance and nancial challenges in the Family Physician Program (FPP) of Iran based on systematic review of the publications