Challenges of the Referral System in Family Medicine Program in Iran: A Scoping Review
,
Abstract
Background: Since its inception in 2005, Iran’s Family Medicine Program has faced persistent challenges in implementing an effective referral system, limiting its potential to optimize healthcare delivery and reduce hospital overcrowding. This scoping review synthesized evidence from 31 studies (2005–2022) to identify and categorize systemic challenges within Iran’s referral system.
Methods: In 2023, a systematic search of English and Persian databases (e.g., PubMed, SID, Magiran) identified studies on referral system challenges. Data were thematically analyzed and mapped to six WHO domains: governance, financing, human resources, equipment, information systems, and service delivery.
Results: Key challenges include: Governance: Fragmented policies, weak oversight and lack of enforceable referral protocols. Financing: Delayed payments to physicians and restrictive insurance tariffs disincentivize compliance. Service Delivery: Public distrust in family physicians, low reverse referral rates, and poor specialist feedback. Technology: Reliance on paper-based referrals and fragmented electronic records. Human Resources: Rural specialist shortages (0.5 per 10,000 in Iran vs. 4.2 in urban areas) drive bypassing of primary care.
Conclusion: Iran’s referral system struggles reflect systemic deficiencies in governance, financing, and infrastructure. Successful reforms require multi-level interventions: digitizing referrals, incentivizing compliance through blended payment models, and rebuilding public trust via awareness campaigns. Lessons from countries like South Korea (differential copayments) and the UK (Shared Care models) highlight pathways for integration. Without urgent action, the Family Medicine Program risks perpetuating inefficiencies and inequities in Iran’s healthcare system.
1. Joolaee H, Alizadeh M, Fallahzadeh MH, et al (2011). Evaluation of clinical skills of family physicians in Fars province by means of observed structured clinical evaluation. Strides Dev Med Educ,7(2):92-8.
2. Dehnavieh R, Movahed E, Rahimi H, et al (2017). Evaluation of the referral system in Iran’s rural family physician program; a study of Jiroft University of Medical Sciences. Electron Physician, 9(4):4225-2430.
3. Hafezi Z, Asqari R, Momayezi M (2009). Monitoring performance of family physicians in Yazd. Biblioteca responsável, 8 (1-2): 16-25
4. Golalizadeh E, Moosazadeh M, Mahammadreza A, et al (2011). Challenges in second level of referral system in family physician plan: a qualitative research. Journal of Medical Council of Islamic Republic of Iran, 29(4):309-21. [Persian].
5. Kabir MJ, Heidari A, Honarvar MR, et al (2021). Management Challenges of Implementing Electronic Patient Referral System; a Qualitative Study. Health Res J, 6 (4):275-286.
6. Organization WH (2010). Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. ed. World Health Organization. Geneva: WHO; 2010.
7. Safizadehe Chamokhtari K, Abedi G, Marvi A, Soltani Kentaie SA, et al (2017). SWOT analysis of implementation of urban family physician plan from the perspective of beneficiaries: A qualitative study. J Mazandaran Univ Med Sci, 27 (155):79-93.
8. Kabir MJ, Amiri HA, Hassanzadeh-Rostami Z, et al (2019). Achievements and challenges in implementing urban family physician program in Iran: viewpoint of managers and executives. Q J Manag Strateg Health Syst, doi:10.18502/mshsj.v4i2.1410.
9. Shirjang A, Mahfoozpour S, Asl IM, et al (2020). Challenges and strategies of implementation rural family physician in iran: a qualitative study. Depict Health, 11 (1):62-73.
10. Naseriasl M, Janati A, Amini A, et al (2018). Referral system in rural Iran: improvement proposals. Cad Saude Publica, 34:e00198516.
11. Mehrolhassani MH, Jafari Sirizi M, Poorhoseini SS, et al (2012). The challenges of implementing family physician and rural insurance policies in Kerman province, Iran: a qualitative study. Health Dev J, 1 (3):193-206.
12. Rouhani S, Bagher M (2015). Experience of family physicians in rural areas regarding referral system and improving it (a qualitative study). J Mazandaran Univ Med Sci, 25 (131):1-13.
13. Zahiri M, Mohamadi E, Najafpoor Z, et al (2017). Survey of General Practitioners Point of View about Family Physician and Referral System Policies in Urban Areas for 2013. Journal of Healthcare Management Research,57-66
14. Kohpeima Jahromi V, Dehnavieh R, Mehrolhasani M (2018). Evaluation of urban family physician program in Iran using primary care evaluation tool. irje, 13:134-144.
15. Torabi Ardakani A, Hosseini S, Nadia O, et al (2015). Study perception, knowledge and expectations from population and physicians points of view about implementation of family physician program: a case study in Shiraz. jmciri, 33(2): 147-155
16. Eskandari M, Abbaszadeh A, Borhani F (2013). Barriers of referral system to health care provision in rural societies in Iran. J Caring Sci, 2 (3):229-36.
17. Nasiripour A, Motaghi M, Navvabi N (2014). The performance of referral system from the perspective of family physicians of Kashan University of Medical Sciences: 2007-20012. JHPM, 3 (3):58-68.
18. Shams A, Ashrafi-rizzi H, Afrough S, et al (2013). A Survey on Clients’ Opinions in Isfahan’s Public Hospitals About Effective Factors in the Fulfillment of Referral System. Acta Inform Med, 21 (1):51-5.
19. Nasrollahpour Shirvani SD, Ashrafian AH, Motlagh M, et al (2010). Evaluation of the function of referral system in family physician program in Northern provinces of Iran: 2008. Journal of Babol University of Medical Sciences, 11(6):46-52
20. Nasrollahpour Shirvani SD, Mikanik E, Ashrafian Amiri H, et al (2014). Evaluation of the referral system situation in family physician program in northern provinces of Iran: 2012-2013. J Mazandaran Univ Med Sci, 23 (109):27-35.
21. Mohammadi BJ, Mohamadi BA, Valiee S, et al (2019). The views of stakeholders about the challenges of Rural Family Physician in Kurdistan Province: a qualitative study. irje, 15 (1)47-56.
22. Eshrati B, HOSSEINI S, Farahani M, et al (2013). Assessing the Referral Rate of Family Medicine Program from the First Level to the Second Level Using Funnel Plot in Markazi Province (Iran) in 2011 J Arak Uni Med Sci, 16(4): 45-53
23. Ebrahimipour H, Hosseini SE, Mahmoudian P, et al (2015). Evaluating the performance of family physician in rural health centers, Bardaskan, 2013. Beyhagh, 20 (2):26-34.
24. Borhaninejad V, Pourebrahimi MH, Nadrian H, et al (2015). Satisfaction of Service Recipients of Family Physician Program in Kerman, 2011. Health Dev J, 4 (1):1-9.
25. Janati A, Amini A, Adham D, et al (2017). Assessing the quality of referral letters written by general practitioners: a cross-sectional study in rural Iran. Cad Saude Publica, 33(2):e00043016.
26. Faramarzi M, Shishegar M, Sabz GA, et al (2019). Quality of Referral Letters Written by Family Physicians to Otologists-A Peer Assessment. Iran J Otorhinolaryngol, 31 (107):369-375.
27. Damari B, Moghaddam AV, Gouran NR, et al (2016). Evaluation of the urban family physician and referral system program in Fars and Mazandran provinces: history, achievements, challenges and solutions. sjsph, 14(2): 17-38
28. Chaman R, Amiri M, Raei M, et al (2011). National family physician program in Shahroud: assessing quality of implementation and condition of settings. Hakim, 14(2): 123-129
29. Motlagh M, Nasrollahpour SS, Ashrafian AH, et al (2011). Satisfaction of family physicians (FPs) about effective factors on activation of FP program in medical universities. JGUMS, 19(76): 48-55
30. Bayati A, Ghanbari F, Maleki A, et al (2015). Effective factors influencing family medicine programme dyanmics with regard to viewpoints of involved physicians: A qualitative study. Basic and Clinical Research Journal , 22 (17):39-48.
31. Rao G (2012). Healthcare financing reform in India's decentralized healthcare system. In. Ed(s), pp. 283-306.
32. Adeloye D, David RA, Olaogun AA, et al (2017). Health workforce and governance: the crisis in Nigeria. Hum Resour Health, 15(1):32.
33. Khodayari-Zarnaq R, Mobasseri K, Ghasemyani S, et al (2024). Challenges and Weaknesses of Leadership and Governance-related Health Policies in Iran: A Systematic Review. Arch Iran Med, 27 (9):508-521.
34. Abimbola S, Negin J, Jan S, Martiniuk A (2014). Towards people-centred health systems: A multi-level framework for analysing primary health care governance in low- and middle-income countries. Health Policy Plan, 2(Suppl 2):ii29-39.
35. Atun R, De Andrade LOM, Almeida G, et al (2015). Health-system reform and universal health coverage in Latin America. Lancet, 385 (9974):1230-47.
36. El-Saharty S, Liu AC (2021). Priorities for Arab Health Policy Makers: The Way Forward. In: Handb Healthc Arab World. Springer, p 3225-3258.
37. Kwon S (2009). Thirty years of national health insurance in South Korea: lessons for achieving universal health care coverage. Health Policy Plan, 24 (1):63-71.
38. Facchini LA, Tomasi E, Dilélio AS (2018). Quality of Primary Health Care in Brazil: advances, challenges and perspectives. Saude Debate, 42:208-223.
39. Perry HB, Sachs JD (2024). The investment case for strengthening primary healthcare and community health worker programs in low-and lower-middle-income countries. Oxf Res Encycl Glob Public Health, doi.org/10.1093/acrefore/9780190632366.013.334.
40. Mohaghegh B, Seyedin H, Rashidian A, et al (2014). Psychological factors explaining the referral behavior of Iranian family physicians. Iran Red Crescent Med J, 16 (4):e13395.
41. Nasrollahpour Shirvani SD, Raeisee P, Motlagh M, et al (2010). Evaluation of the Performance of Referral System in Family Physician Program in Iran University of Medical Sciences: 2009. Hakim J, 13 (1):19-25.
42. Barzegari J, Aryankhesal A, Moinfar Z, et al (2021). Non-communicable diseases units: continuity of care factors. J Public Health (Oxf), 29:653-657.
43. Barzegari J, Raeissi P, Hashemi S-M, et al (2023). Delivering Primary Health Care (PHC) Services for Controlling NCDs During the COVID-19 Pandemic: A Scoping Review. J Prev(2022), 44 (5):579-601.
44. Barzegari J, Raeissi P, Reisi N, Hashemi M, et al (2023). Examining the care of noncommunicable diseases at the first level of providing services during the COVID-19 pandemic. Z Gesundh Wiss,17:1-6.
45. Horne R, Mailey E, Frost S, et al (2001). Shared care: a qualitative study of GPs' and hospital doctors' views on prescribing specialist medicines. Br J Gen Pract, 51 (464):187-193.
46. Adams JS, Freedman S (1976). Equity theory revisited: Comments and annotated bibliography. Adv Exp Soc Psychol, 9:43-90.
47. Ahonen O, Tana J, Lejonqvist G-B, et al (2018). The Development of Digital Health and Welfare Services in Estonia, Finland and Latvia. https://www.theseus.fi/handle/10024/152399
2. Dehnavieh R, Movahed E, Rahimi H, et al (2017). Evaluation of the referral system in Iran’s rural family physician program; a study of Jiroft University of Medical Sciences. Electron Physician, 9(4):4225-2430.
3. Hafezi Z, Asqari R, Momayezi M (2009). Monitoring performance of family physicians in Yazd. Biblioteca responsável, 8 (1-2): 16-25
4. Golalizadeh E, Moosazadeh M, Mahammadreza A, et al (2011). Challenges in second level of referral system in family physician plan: a qualitative research. Journal of Medical Council of Islamic Republic of Iran, 29(4):309-21. [Persian].
5. Kabir MJ, Heidari A, Honarvar MR, et al (2021). Management Challenges of Implementing Electronic Patient Referral System; a Qualitative Study. Health Res J, 6 (4):275-286.
6. Organization WH (2010). Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. ed. World Health Organization. Geneva: WHO; 2010.
7. Safizadehe Chamokhtari K, Abedi G, Marvi A, Soltani Kentaie SA, et al (2017). SWOT analysis of implementation of urban family physician plan from the perspective of beneficiaries: A qualitative study. J Mazandaran Univ Med Sci, 27 (155):79-93.
8. Kabir MJ, Amiri HA, Hassanzadeh-Rostami Z, et al (2019). Achievements and challenges in implementing urban family physician program in Iran: viewpoint of managers and executives. Q J Manag Strateg Health Syst, doi:10.18502/mshsj.v4i2.1410.
9. Shirjang A, Mahfoozpour S, Asl IM, et al (2020). Challenges and strategies of implementation rural family physician in iran: a qualitative study. Depict Health, 11 (1):62-73.
10. Naseriasl M, Janati A, Amini A, et al (2018). Referral system in rural Iran: improvement proposals. Cad Saude Publica, 34:e00198516.
11. Mehrolhassani MH, Jafari Sirizi M, Poorhoseini SS, et al (2012). The challenges of implementing family physician and rural insurance policies in Kerman province, Iran: a qualitative study. Health Dev J, 1 (3):193-206.
12. Rouhani S, Bagher M (2015). Experience of family physicians in rural areas regarding referral system and improving it (a qualitative study). J Mazandaran Univ Med Sci, 25 (131):1-13.
13. Zahiri M, Mohamadi E, Najafpoor Z, et al (2017). Survey of General Practitioners Point of View about Family Physician and Referral System Policies in Urban Areas for 2013. Journal of Healthcare Management Research,57-66
14. Kohpeima Jahromi V, Dehnavieh R, Mehrolhasani M (2018). Evaluation of urban family physician program in Iran using primary care evaluation tool. irje, 13:134-144.
15. Torabi Ardakani A, Hosseini S, Nadia O, et al (2015). Study perception, knowledge and expectations from population and physicians points of view about implementation of family physician program: a case study in Shiraz. jmciri, 33(2): 147-155
16. Eskandari M, Abbaszadeh A, Borhani F (2013). Barriers of referral system to health care provision in rural societies in Iran. J Caring Sci, 2 (3):229-36.
17. Nasiripour A, Motaghi M, Navvabi N (2014). The performance of referral system from the perspective of family physicians of Kashan University of Medical Sciences: 2007-20012. JHPM, 3 (3):58-68.
18. Shams A, Ashrafi-rizzi H, Afrough S, et al (2013). A Survey on Clients’ Opinions in Isfahan’s Public Hospitals About Effective Factors in the Fulfillment of Referral System. Acta Inform Med, 21 (1):51-5.
19. Nasrollahpour Shirvani SD, Ashrafian AH, Motlagh M, et al (2010). Evaluation of the function of referral system in family physician program in Northern provinces of Iran: 2008. Journal of Babol University of Medical Sciences, 11(6):46-52
20. Nasrollahpour Shirvani SD, Mikanik E, Ashrafian Amiri H, et al (2014). Evaluation of the referral system situation in family physician program in northern provinces of Iran: 2012-2013. J Mazandaran Univ Med Sci, 23 (109):27-35.
21. Mohammadi BJ, Mohamadi BA, Valiee S, et al (2019). The views of stakeholders about the challenges of Rural Family Physician in Kurdistan Province: a qualitative study. irje, 15 (1)47-56.
22. Eshrati B, HOSSEINI S, Farahani M, et al (2013). Assessing the Referral Rate of Family Medicine Program from the First Level to the Second Level Using Funnel Plot in Markazi Province (Iran) in 2011 J Arak Uni Med Sci, 16(4): 45-53
23. Ebrahimipour H, Hosseini SE, Mahmoudian P, et al (2015). Evaluating the performance of family physician in rural health centers, Bardaskan, 2013. Beyhagh, 20 (2):26-34.
24. Borhaninejad V, Pourebrahimi MH, Nadrian H, et al (2015). Satisfaction of Service Recipients of Family Physician Program in Kerman, 2011. Health Dev J, 4 (1):1-9.
25. Janati A, Amini A, Adham D, et al (2017). Assessing the quality of referral letters written by general practitioners: a cross-sectional study in rural Iran. Cad Saude Publica, 33(2):e00043016.
26. Faramarzi M, Shishegar M, Sabz GA, et al (2019). Quality of Referral Letters Written by Family Physicians to Otologists-A Peer Assessment. Iran J Otorhinolaryngol, 31 (107):369-375.
27. Damari B, Moghaddam AV, Gouran NR, et al (2016). Evaluation of the urban family physician and referral system program in Fars and Mazandran provinces: history, achievements, challenges and solutions. sjsph, 14(2): 17-38
28. Chaman R, Amiri M, Raei M, et al (2011). National family physician program in Shahroud: assessing quality of implementation and condition of settings. Hakim, 14(2): 123-129
29. Motlagh M, Nasrollahpour SS, Ashrafian AH, et al (2011). Satisfaction of family physicians (FPs) about effective factors on activation of FP program in medical universities. JGUMS, 19(76): 48-55
30. Bayati A, Ghanbari F, Maleki A, et al (2015). Effective factors influencing family medicine programme dyanmics with regard to viewpoints of involved physicians: A qualitative study. Basic and Clinical Research Journal , 22 (17):39-48.
31. Rao G (2012). Healthcare financing reform in India's decentralized healthcare system. In. Ed(s), pp. 283-306.
32. Adeloye D, David RA, Olaogun AA, et al (2017). Health workforce and governance: the crisis in Nigeria. Hum Resour Health, 15(1):32.
33. Khodayari-Zarnaq R, Mobasseri K, Ghasemyani S, et al (2024). Challenges and Weaknesses of Leadership and Governance-related Health Policies in Iran: A Systematic Review. Arch Iran Med, 27 (9):508-521.
34. Abimbola S, Negin J, Jan S, Martiniuk A (2014). Towards people-centred health systems: A multi-level framework for analysing primary health care governance in low- and middle-income countries. Health Policy Plan, 2(Suppl 2):ii29-39.
35. Atun R, De Andrade LOM, Almeida G, et al (2015). Health-system reform and universal health coverage in Latin America. Lancet, 385 (9974):1230-47.
36. El-Saharty S, Liu AC (2021). Priorities for Arab Health Policy Makers: The Way Forward. In: Handb Healthc Arab World. Springer, p 3225-3258.
37. Kwon S (2009). Thirty years of national health insurance in South Korea: lessons for achieving universal health care coverage. Health Policy Plan, 24 (1):63-71.
38. Facchini LA, Tomasi E, Dilélio AS (2018). Quality of Primary Health Care in Brazil: advances, challenges and perspectives. Saude Debate, 42:208-223.
39. Perry HB, Sachs JD (2024). The investment case for strengthening primary healthcare and community health worker programs in low-and lower-middle-income countries. Oxf Res Encycl Glob Public Health, doi.org/10.1093/acrefore/9780190632366.013.334.
40. Mohaghegh B, Seyedin H, Rashidian A, et al (2014). Psychological factors explaining the referral behavior of Iranian family physicians. Iran Red Crescent Med J, 16 (4):e13395.
41. Nasrollahpour Shirvani SD, Raeisee P, Motlagh M, et al (2010). Evaluation of the Performance of Referral System in Family Physician Program in Iran University of Medical Sciences: 2009. Hakim J, 13 (1):19-25.
42. Barzegari J, Aryankhesal A, Moinfar Z, et al (2021). Non-communicable diseases units: continuity of care factors. J Public Health (Oxf), 29:653-657.
43. Barzegari J, Raeissi P, Hashemi S-M, et al (2023). Delivering Primary Health Care (PHC) Services for Controlling NCDs During the COVID-19 Pandemic: A Scoping Review. J Prev(2022), 44 (5):579-601.
44. Barzegari J, Raeissi P, Reisi N, Hashemi M, et al (2023). Examining the care of noncommunicable diseases at the first level of providing services during the COVID-19 pandemic. Z Gesundh Wiss,17:1-6.
45. Horne R, Mailey E, Frost S, et al (2001). Shared care: a qualitative study of GPs' and hospital doctors' views on prescribing specialist medicines. Br J Gen Pract, 51 (464):187-193.
46. Adams JS, Freedman S (1976). Equity theory revisited: Comments and annotated bibliography. Adv Exp Soc Psychol, 9:43-90.
47. Ahonen O, Tana J, Lejonqvist G-B, et al (2018). The Development of Digital Health and Welfare Services in Estonia, Finland and Latvia. https://www.theseus.fi/handle/10024/152399
| Files | ||
| Issue | Vol 54 No 9 (2025) | |
| Section | Review Article(s) | |
| DOI | https://doi.org/10.18502/ijph.v54i9.19852 | |
| Keywords | ||
| Referral system Family medicine Healthcare challenges Health system reform Iran | ||
| Rights and permissions | |
|
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Barzegari J, Abolhasani Shahreza F. Challenges of the Referral System in Family Medicine Program in Iran: A Scoping Review. Iran J Public Health. 2025;54(9):1831-1841.
