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Abstract
Background The COVID-19 outbreak at the end of 2019 severely impacted global healthcare systems, especially primary healthcare services. This paper aimed to identify the implications derived from the strengths and weaknesses observed in Iran’s primary healthcare (PHC) programmes during the pandemic.
Methods This was a qualitative study conducted in 2021. 13 semistructured interviews were held with Iranian healthcare policymakers and executive managers, selected via snowball sampling, using the World Health Organization’s analytical framework. Finally, a thematic analysis was conducted on the interview data.
Results The thematic analysis of the findings yielded five major themes: revision of healthcare financing, redefining education and research in primary healthcare, redefinition of primary healthcare, development of a new model for family medicine, and community engagement.
Conclusion Addressing vertical inequality in Iran’s healthcare system was delineated to be crucial. Meanwhile, multiple strategies including enhancing family physicians’ knowledge and skills, decentralising decision-making, empowering them and involving communities in healthcare planning were presented to improve PHC and family medicine. Further empirical research is needed.
- COVID-19
- Public health
- Emergency Service, Hospital
- Health
- Health Services
- Primary Health Care
Data availability statement
Data are available upon reasonable request. The data of the research are available through making contact with the corresponding author.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The study involved prominent healthcare policymakers and executive managers as participants.
The study did not include the perspectives of participants in the primary healthcare system in Iran, particularly ordinary civilians.
Introduction
The emergence of the COVID-19 virus at the end of 2019 precipitated a global crisis.1 The comprehensive impact of this disease on people’s lives has led policymakers and healthcare system decision-makers to consider whether healthcare systems had demonstrated sufficient resilience to confront the pandemic.2
Resilience, in the context of healthcare systems, is defined as the ability of a healthcare system to prepare for and manage—through absorption, adaptation and transformation—the impacts of sudden events and occurrences.3 Indeed, a healthcare system can only successfully navigate a crisis when, in addition to maintaining its core objectives, it is capable of evolving and improving. However, this outcome was rarely observed during the COVID-19 pandemic, during which the disruption of certain routine healthcare services occurred within the first year of the response.4–6 Identifying the strengths and weaknesses of healthcare systems and their governance, as well as assessing their responsiveness in facing pandemics, can facilitate a more accurate understanding of the path forward and enhance readiness to cope with such uncertain circumstances in the future.
Healthcare systems worldwide have employed various strategies to contain the COVID-19 pandemic. It appears that having a coherent crisis management plan has been a determining factor among them. Countries with comprehensive plans were able to effectively manage the pandemic and mitigate its harmful effects by implementing appropriate policies, including widespread testing and tracing, fostering public trust and transparency in communication, strengthening primary healthcare systems, and implementing effective screening and quarantine measures.7 In this regard, COVID-19’s global lessons emphasise the need for a heightened focus on global health security, public health and primary healthcare (PHC). Given the broad social and economic impacts of pandemics, a holistic approach to healthcare, particularly one that emphasises primary care, offers an appropriate response to the challenges affiliated with the pandemics.8–11
Evidence suggests that significant non-pharmaceutical interventions in PHC settings have been successful strategies for controlling and managing pandemics. Essential to this approach are appropriate risk assessments within communities and pre-designed structures for community engagement to improve health outcomes.12–15 For instance, communities with high health literacy and robust social capital have demonstrated better adherence to health protocols, resulting in lower infection rates.16 17 This highlights the imperative for appropriate focus and policymaking grounded in the fundamental principles of PHC.
Prior to the COVID-19 pandemic, Iran had made substantial investments in its PHC system, launching a flagship programme focused on disease prevention and health promotion through a comprehensive network of community health centres (CHCs) and health posts. With the onset of the pandemic, this established infrastructure was strategically leveraged by designating approximately 1050 CHCs as specialised COVID-19 centres to manage mild cases and conduct contact tracing. This approach not only alleviated the pressure on hospitals by redirecting patient flow but also ensured the continuity of essential health services.18 19
Several studies have been undertaken to examine the implications of the Iranian primary healthcare system’s experience throughout the COVID-19 pandemic. In this regard, one study highlighted a whole-of-government approach that strengthened primary healthcare capacity, supported the workforce, improved preparedness, ensured access to medicines and vaccines, and used health information systems.20 A study conducted to assess the impact of the Healthcare Incident Command System (HICS) on district health networks (DHNs) in Iran during the COVID-19 pandemic found that DHNs with active HICS achieved significantly higher scores in incident management and command than those without active HICS, particularly in areas such as organisational support, planning and communication. The findings indicated that the implementation of HICS positively influenced incident management capabilities, underscoring its potential to enhance crisis management for infectious diseases and to improve the overall efficiency of primary healthcare system responses during such emergencies.21
A review of the existing literature reveals a lack of comprehensive reports detailing the implications derived from the experiences of Iran’s PHC system during the COVID-19 pandemic. Conducting such studies is of significant value for stakeholders, including PHC policymakers and managers in countries with contexts similar to Iran. The insights gained from these analyses can inform the prioritisation of strategies aimed at strengthening the resilience and preparedness of PHC systems in the face of future pandemics and comparable crises.
Materials and methods
Study design
The present research employed a qualitative approach in the year 2021. In this regard, this study conducted multiple semistructured interviews using the analytical framework of the WHO.22
Research question
The research question was designed as the following: ‘What are the implications derived from the strengths and weaknesses observed in PHC programs in the Iranian healthcare system during the COVID-19 pandemic crisis?’.
Sampling method and sample size
Interviews were conducted with 13 policymakers and executive managers of the Iranian healthcare network. Participants were selected using snowball sampling, initially interviewing the Deputy of Health of a medical university in southwestern of Iran, who then facilitated the identification of relevant individuals in the field. The participants comprised 69% males and 31% females. In terms of professional roles, 23% of the participants were Deputies of Health at the university, another 23% served as Deputies of Technical and Operational Affairs, and 23% held the position of Head of the Network Development and Health Promotion Group. Additionally, 15% of the experts were Health Policy Makers, while the remaining 16% were University Professors.
Patient and public involvement
None.
Data collection and inclusion criteria
Multiple semistructured interviews were conducted face-to-face, primarily at the participants’ workplaces, in accordance with the interviewees’ preferences and following prior coordination. Participants were chosen based on their significant awareness and expertise in crisis management and policymaking related to the COVID-19 pandemic. MM, a male with a PhD, with multiple experiences of conducting such methodologies conducted the interviews.
The semistructured interview guide, consisting of five questions, was developed based on a comprehensive discussion of the results derived from the existing literature and the prior personal experiences of two of the manuscript’s authors, who were specialised in the context of primary healthcare in Iran during the COVID-19 pandemic. Subsequently, the guide was validated by two additional experts. Additionally, the face validity of the interview guide was confirmed through three preliminary interviews with participants. The semistructured interview comprised of the following questions:
In your opinion, what are the most important strategies and policies for strengthening the primary healthcare network system? Please explain.
Community participation and interaction with society is one of the principles of primary healthcare. How can we achieve this important goal?
Despite the emphasis of health policymakers at various times on the priority of prevention over treatment, especially in the discussion of resource allocation, this issue is still neglected. What are the reasons for this problem? Please explain.
How should our education and research system be in order to achieve the goals of primary healthcare? Especially, the discussion of Health Systems Research which has been raised for years but is practically inactive.
It seems that during the pandemic, the capacity of healthcare networks was not used as it should have been. How should we employ this potential capacity in practice and overall, what changes and lessons can be taken from the pandemic to improve the healthcare network system?
At the outset of each interview, a verbal explanation regarding identity of the interviewer and the study, particularly its objectives, and the measures taken to ensure confidentiality of information was provided. Written informed consent was obtained from all participants, assuring them of their freedom to withdraw from the study at any stage. Interviews lasted a minimum of 50 min and were conducted solely by one of the authors. With participants’ permission, interviews were recorded and transcribed verbatim shortly after completion. Interviews continued until saturation was reached, with saturation achieved after 13 interviews.
Data management and analysis
To analyse the data, a five-stage framework analysis method was employed. Initially, in the first stage, the audio files from multiple sessions were listened to by the researchers to acquaint themselves with the data, and transcribed texts were reviewed multiple times. In the second stage, to identify a thematic framework, recurring ideas from the familiarisation process were grouped into clusters of similar ideas, or codes. In the third stage, indexing was performed, identifying units or sections of the data relevant to specific codes. Following indexing in the fourth stage, the data were summarised into code tables according to the thematic framework. Finally, in the fifth stage, the data were amalgamated, and a map and interpretation were used to define concepts, illustrate relationships between concepts, specify the nature of the phenomenon and provide explanations and recommendations.23 Due to the language of the text of the interview transcripts (Persian) and to enhance creativity, manual coding and classification methods were employed instead of software utilisation.
Data reliability and validity
In order to enhance the accuracy and reliability of the study data, four criteria of Guba and Lincoln, namely, credibility, confirmability, dependability and transferability, were used.24 In this regard, to bolster the credibility of the study, a prolonged engagement and continuous observation approach were employed, whereby the researchers fully immersed in the research, established appropriate and meaningful communication with participants, and embraced profound concepts emerging throughout the study process. To increase result confirmation capability, the coded data were made available to participants for validation of the extracted findings. To enhance the transferability of study results, conditions of participant awareness and interview methodology were transparently delineated. Efforts were made to ensure the selection of sample individuals was entirely aligned with the study objectives and free from any bias. Data analysis was conducted concurrently with data collection. Moreover, the researchers initially aimed to maintain a thorough understanding of the study’s theoretical foundations to ensure a precise and valid data analysis, as prior knowledge of these foundations is considered essential—particularly during the coding process and theme development. To reinforce result reliability, the process of coding concepts, themes, and textual and auditory information was documented. Additionally, to ensure confidence, two members of the research team (RI and MM) independently analysed the content and engaged in discussions and exchanges of opinions to resolve any discrepancies.
Results
The thematic analysis of the interview involved identifying five main themes and 17 subthemes, as outlined in table 1.
Thematic analysis of the data
Revision of healthcare financing
This theme comprised of three subthemes. The subthemes addressed the reformation of the healthcare budgeting system, revision of payment systems and efficiency and effectiveness of healthcare services. In this context, the interview data highlighted several key points, including the allocation of funds to bolster PHC, the delegation of financial authority, the reduction of healthcare expenses, weaknesses observed in fee-for-service systems, the utilisation of combination payment methods, strategic purchasing practices, and the consolidation of financial resources.
Iranian budgetary allocation systems and expenditure allocation for primary healthcare do not fulfil the necessary effectiveness and efficiency criteria, as observed by contributors. A contributor in this regard stated:
Allocations are crucial resources that must be implemented in a manner that strengthens the primary care network. We’ve seen numerous health deputies wanting to execute plans but lacking the necessary funding and allocation.
Moreover, another contributor stated:
Our most sustainable resource is the discussion of a one percent value-added tax (VAT), initially earmarked for rural areas, towns with fewer than twenty thousand inhabitants, and subsequently for the Exchange Council and other purposes. However, if you look at its trend, this allocation has decreased annually and even received less than fifty percent of its designated funds in the past two years.
Contributors to this research emphasised the inefficiencies of the current payment system in the Iranian healthcare system. One participant with executive experience in healthcare policy and management stated:
When we talk about primary healthcare (PHC), it means that our PHC centers should serve as hubs from which all healthcare system activities initiate, are directed, and coordinated, as they yield greater benefits. However, does our level of expertise allow this to happen? Certainly not, because we have a flawed payment system called fee-for-service, which incentivizes unnecessary treatments and neglects preventive care.
One of the issues raised in this study was the existence of inefficiency and ineffectiveness in the strategic procurement and consolidation of financial resources in PHC of Iran. According to the study participants, financial resource fragmentation in Iran’s healthcare system is a major financing problem, attributed to the multitude of insurance funds and their disjointedness, leading to inefficiencies in resource procurement and allocation. In this regard, one contributor stated:
Health insurance should procure service packages based on service efficiency and effectiveness, adopting a more health-oriented approach and expanding coverage. This necessitates the establishment of a unified electronic health record and rigorous supervision by insurance organizations. Additionally, insurance organizations, as service buyers, must actively engage in preventive measures.
Redefining education and research in primary healthcare
This theme comprised of three subthemes. The subthemes addressed the revision of family medicine educational system, alignment of education with primary healthcare and evidence-based policymaking. In this regard, the interview data highlighted several key initiatives. These included the training of physicians in accordance with family medicine principles and PHC, the establishment of dedicated educational centres for family physician training, and the integration of parallel educational facilities. Moreover, efforts were focused on enhancing PHC through research and education, as well as ensuring the completion of Master of Public Health courses for family physicians. Additionally, there was a strong emphasis on aligning policymaking and implementation in decisions concerning pandemics, alongside the adoption of evidence-based decision-making approaches.
According to one of the study participants, the medical education system in Iran is predominantly treatment-oriented, where physicians are trained with a hospital-centric approach. Subsequently, many of these physicians are employed in rural family physician centres. It is evident that the lack of sufficient training focused on family medicine and primary healthcare leads to insufficient efficiency among these physicians. In this regard, one contributor stated:
We educate physicians with a treatment-oriented and hospital-centric approach, lacking fundamental education in public health and family medicine at universities. Then, we place these physicians in healthcare centers and expect them to work in line with the goals of primary healthcare (PHC). This approach is flawed; the medical education curriculum needs to be revised, or at the very least, general physicians should be trained specifically for family medicine from the outset.
One of the contributors emphasised the integration of parallel educational institutions in the Iranian healthcare system. The Health Deputy is one of the deputy ministries of the Ministry of Health and employs the majority of graduates in public health-related fields. Additionally, this deputy oversees a subset known as the Health Education Center, responsible for the training of health workers (multipurpose health workers in rural areas) since the establishment of the healthcare network. Contributors stressed the need for upgrading and improving the educational status. In this regard, the contributor stated:
In our network system, we have health education centers responsible for training health workers (multipurpose health workers of the Iranian healthcare system), which lack communication with health faculties. One fundamental change that could enhance the scientific and academic level of this group could be the integration of these educational centers into health faculties of universities. Furthermore, the Health Deputy practically has no connection with health faculties. It would be better if health ministries and their subsets were integrated into health faculties to facilitate better student involvement in fieldwork and strengthen the healthcare system.
In such context, another contributor remarked:
Medical students are trained in a way that they become disillusioned and believe that their salvation lies in specialization and sub-specialization. Currently, family medicine specialists are trained with a highly sophisticated treatment-centric approach, which is truly a dangerous trend. These are the issues that require careful consideration. Primary healthcare has no place in our education and research, and these are matters that need to be addressed at the university level.
The reformation of the recruitment process for health workers in rural areas and their training methods emerged as a prominent issue in the research. In this regard, one contributor expressed:
Previously, we utilized individuals with basic education levels for health worker recruitment, as societal and economic conditions necessitated. However, with the changing societal landscape, increased literacy, and knowledge levels, the previous recruitment and training methods for health workers are no longer adequate. It is preferable that recruitment, employment, and training procedures for health workers adapt to the evolving needs and capabilities of society.
Applied research in alignment with primary healthcare emerged as a topic of discussion. One participant emphasised the need for research centred on primary healthcare:
Research based on primary healthcare (PHC) should be prioritized. Our Health Systems Research (HSR) units are not sufficiently active in most networks and often become merely ceremonial. It is imperative to integrate ideas for improving primary healthcare into the network’s structure and research agendas.
Evidence-based policymaking was identified as a key theme. One participant advocated for the creation of a policy roadmap, stating:
Consider the necessary actions… one of which is evidence-based decision-making. To achieve this, we need a research political mapping, essentially a scientific policy roadmap. This involves extracting specific research questions necessary for policymaking. These questions can then be transformed into proposals or Requests for Proposals (RFPs) for interested parties to engage with. Subsequently, these proposals are converted into scientific recommendations, which are then reviewed by scientific committees and transformed into policies. These policies are then deliberated at the national level and converted into decisions. This process ensures evidence-based decision-making because each entity plays a distinct role. For instance, as a researcher, I shouldn't expect all my proposals to be implemented immediately the next day, as economic and political factors also influence decision-making. It is the committee’s duty to evaluate proposals from various perspectives.
Redefinition of primary healthcare
This theme comprised of five subthemes. The subthemes addressed the enhancement of health education, revision of treatment-oriented approach, redefining crisis management in the healthcare network system, reviewing infectious disease management, and reorganisation of the healthcare service delivery network. In this context, the interview data underscored several significant areas for consideration. These encompassed the improvement of health literacy, re-evaluation of PHC definitions and the promotion of discourse surrounding primary healthcare within the community. Moreover, concerns were raised regarding excessive specialisation and a hospital-centric approach in healthcare delivery. Efforts were suggested for the development of crisis-appropriate infrastructure, risk assessment and preparation for high-risk encounters with future epidemics. Recommendations were also made for strengthening the Centers for Disease Control and Prevention, enhancing surveillance systems and addressing the overemphasis on non-communicable diseases. Additionally, strategies were proposed for increasing the availability of health houses and active health bases in service delivery, decentralising the healthcare network system, fostering public-private partnerships and ensuring the appropriate staffing of organisational positions within the healthcare network.
Regarding this theme, the study contributors stressed the importance of promoting a primary healthcare discourse in society and improving health literacy:
If health literacy in our society is low, the healthcare system must be responsive. The responsibilities within the healthcare system should extend beyond merely treating symptomatic illnesses like COVID-19, and community-centered family medicine should be fully implemented.
He stated further:
Efforts were made to disseminate this discourse in society through the media, exemplified by a positive initiative in Mazandaran province where family physicians engaged with the community by answering their questions. However, despite initial progress, there has been a regression to previous structures, leaving this initiative largely neglected.
According to one of the study participants, a critical need is to revise the treatment-oriented approach. In this regard, the participant stated:
Family physicians are healthcare providers who focus on preventive care and healthcare discussions. However, it is observed that this aspect is not adequately incorporated into the family physician model in our country. Even in rural areas, the primary task was primarily seen as diagnosing and referring patients urgently, rather than focusing on preventive care. Primary Healthcare should entail both skilled human resources and a robust surveillance system. Unfortunately, we lacked a comprehensive healthcare system.
Another participant highlighted the adverse effects of excessive specialisation and hospital-centric approaches on the failure of primary healthcare programmes. The participant stated:
Unfortunately, this trend persists in our country, and it requires a tactful and scientifically grounded approach to address it.
Reorganisation emerged as one of the identified subthemes in this research. According to participants, strengthening and redefining primary healthcare necessitate the creation of new specialist positions, including epidemiologists, activating currently inactive service centres, and completing organisational structures by hiring more human resources for primary healthcare. One contributor stated:
If we look at the statistics, we have approximately 1000 inactive health centers and nearly an equal number of inactive urban centers in the country. One of the initial steps towards strengthening the network should be focusing on these statistics and activating these service centers.
According to one of the study participants, a significant portion of secondary-level healthcare services in Iran is managed by the private sector. However, the Ministry of Health has limited oversight in this area, and collaboration between the private and public sectors has not been satisfactory. In this regard, the participant commented:
The involvement of the private sector is another important issue. Frankly, we either fear or lack trust in the private sector. Implementing the family physician program without involving the private sector is not feasible. The private sector should assist us in screening and providing comprehensive services based on health protocols.
Development of a new model for family medicine
This theme comprised of five subthemes. The subthemes included the systematic thinking in healthcare, family medicine improvement, integration of services, and digital health. In this context, the interview data highlighted several critical issues, including the preservation of programmes and objectives amidst management changes, the confinement of the family medicine programme within the health department of the Ministry of Health, identification of conflicts of interest at specialised levels, consideration of service recipients’ perspectives, ensuring the provision of quality services, addressing instances of neglect within the community, demonstrating sincere commitment and confidence in the execution of family physician roles, establishing a professional association for family physicians, reviewing primary care service packages, promoting the integration of services across primary and secondary healthcare levels, revising and enhancing the referral system, integrating information systems for improved coordination, facilitating easy access to epidemiological data for researchers, ensuring staff readiness for digital health initiatives, and implementing electronic medical records within the disease care system.
According to one of the study participants, systemic thinking is an essential and undeniable aspect of healthcare system management. In this regard, the structure of healthcare management in Iran undergoes significant changes with each change in government or senior management, leading to the neglect of previous management plans. This issue hampers improvement in healthcare management and policymaking. The participant expressed:
We know all the weaknesses and strengths. Now the question is, where is the institution responsible for addressing these problems and making decisions for reform and implementation? Can governments that change every four years or health ministries that didn't know who their health minister was until a week or two ago have plans? Thinking that one person has a plan means what? Can you have a plan without a team? Can you have a plan without continuous work for years? Can you have a plan without executive and research fields that have implemented these models…
According to one of the study participants, service integration at the primary and secondary levels and having a referral system in line with standards are prerequisites for enhancing primary healthcare programmes. While primary care services are somewhat uniform in our healthcare system, they still have weaknesses. However, this uniformity is not observed at higher and specialised levels due to the lack of a proper referral system and incomplete implementation of urban family physician programmes. The participant stated:
Integration represents a form of coordination, even when we consider horizontal integration, which examines whether integrated services are provided at a single level. The level of coordination is such that, for example, if I require a visit to an endocrinologist and simultaneously need psychiatric care at the same level, is a neurologist truly provided in an integrated manner to an individual? If so, we would claim there is coordination between healthcare levels; however, in reality, this is not the case. There is neither vertical integration nor horizontal integration among the first, second, and third levels of healthcare.
According to one of the study participants, digital health and progress in that direction have been among the most important lessons learnt from the COVID-19 pandemic worldwide. Unfortunately, in Iran, the necessary infrastructure for moving in this direction is still lacking. Even electronic health records have long-standing issues such as lack of integration, accuracy and timeliness of information. Regarding this issue, the participant stated:
Our information systems are not interconnected and unified. The future of the healthcare system is moving towards digitization, and plans should be made so that even medical infrastructure moves towards telehealth and digitalization.
Community engagement
This theme comprised of two subthemes. The subthemes addressed the community role in improving primary healthcare and attention to mass media. In this context, the interview data presented several significant findings: observations pertaining to cultural promotion initiatives, identification of social initiatives aimed at engaging public participation, consideration given to the social aspects of COVID-19, highlighting the community’s role in needs assessment and prioritisation of health services, concerns raised regarding the neglect of PHC in mass media coverage, and emphasis placed on the media’s role in promoting the importance of family physicians.
Regarding this theme, the study participants emphasised the overlooked role of primary healthcare in the mass media and the importance of cultural awareness and involving people in health-related decision-making. One participant stated:
Involving people is very important. Unfortunately, the current interaction with society is not called community engagement. Having so many healthcare providers alone does not lead to progress. Engaging people should involve needs assessment, prioritization, evaluation, and implementation, as seen in reports from the World Health Organization. The success of the network system depends on the level of people’s participation, a phenomenon which can particularly addressed by the mass media throughout the country.
Another participant stated:
…Regarding the issue of service stakeholders, which are always present in planning but often ignored, I believe that if we want to have family medicine, it must become a demand of the people. There should be such strong cultural awareness and preparedness among the people that they demand it and become advocates for implementing family medicine.
Discussion
As the findings of the study delineated, the thematic analysis of the study data led to five major themes providing implications derived from the observed strengths and weaknesses of Iranian healthcare system during the COVID-19 pandemic. In this regard, most of the study findings, including those related to management, financing, workforce, digital health, education and community engagement, were consistent with the existing literature.25–31 Meanwhile, certain study findings were considered novel within the literature, particularly those related to policymaking and systematic thinking. More importantly, the data reported in our study are considered to be rich in insights and detail in comparison with the existing literature. In this section of the study, each of the themes is discussed and analysed thoroughly.
Revision of healthcare financing
The studies within the literature backed our findings regarding the necessity of revision of healthcare financing after the experience of the COVID-19 pandemic. In this regard, the reports have indicated that the pandemic has had a significant impact on Iran’s health system, underscoring the urgent need for flexible financing and increased resources to improve service accessibility.32 Additionally, there is a pressing need to address out-of-pocket payments and their detrimental effects on healthcare access, particularly among impoverished populations.33 In this regard, it is recommended that the Iranian healthcare system addresses its vertical inequity through implementing the following strategies:
Universal insurance coverage.34
Redistributing incomes within the health sector to support low-income individuals.34
Strengthening health insurance schemes to enhance equity.34
Additional reports within the literature have backed the findings of our study underscoring the difficulties encountered by healthcare centres amidst the pandemic, noting substantial shifts in financial and performance metrics, including decreased revenues and resources.35 36 In this regard, the following points are emphasised:
Financial assistance and sustainable resource allocation during crises.36
Implementing suitable models for service enhancement and resource sustainability during such challenging periods.35
These findings indicate that healthcare policymakers and managers must implement effective models of healthcare delivery networks within their respective organisations. In doing so, they should carefully consider the essential resources required to respond adequately to crises and disruptions in the standard healthcare service delivery processes.
Redefining education and research in primary healthcare
Studies in the literature have corroborated our findings regarding the imperative to redefine education and research within Iran’s primary healthcare sector. There has been an emphasis on the necessity for enhancements in planning, monitoring and governance.37 Additionally, the pivotal challenge concerning training systems within Iran’s primary healthcare, indicating the need for immediate attention, has been highlighted.38 These findings underscore the importance of prioritising education and research within healthcare systems to improve preparedness for crises.
The literature highlights the following points to address such challenges:
The need for comprehensive training to address deficiencies in knowledge and skills among family physicians.39 40
Involving specialists in the training of generalists which can enhance the ongoing professional development of family physicians, thereby ensuring the success of the Family Physician Program in Iran.40
Redefinition of primary healthcare
The literature supports our findings regarding this theme reporting the necessity of enhancing health literacy, particularly among male individuals, older adults, individuals with limited educational attainment, and those residing in rural areas in Iran.41 Meanwhile, it is reported that improved access to the internet and information and communication technologies can play a significant role in augmenting patients’ health literacy. Additionally, the development of more effective patient education strategies is paramount to this endeavour.38 These findings highlight the importance of emphasising population health literacy and the utilisation of digital tools to enhance the preparedness of healthcare systems during crises.
The literature has also highlighted the imperative to confront challenges within primary PHC in Iran, including a centralised decision-making process, parallel service delivery structures, inadequate understanding of health packages, disparities between current and necessary staff competencies, and delayed health needs assessments. Additionally, the following implications have been underscored to be significant steps forward:
Development of a new model for family medicine
The literature has corroborated our findings concerning the imperative need for restructuring family medicine in Iran. Various challenges pertaining to the legal framework, administrative processes and societal structure have been documented.39 Additionally, obstacles related to organisational accessibility, financial provisions for secondary healthcare and cultural considerations have been highlighted.43 These findings emphasise the vital role of family medicine in primary healthcare services during crises, which healthcare policymakers and managers should carefully take into account.
The literature has proposed several strategies to improve family medicine in Iran:
Clarifying the future roles and privileges of trained physicians.44
Selecting motivated applicants to enhance educational quality.44
Focusing on shorter, skill-focused courses to empower general practitioners.44
Ensuring the applicability of training.44
Implementing continuous monitoring and evaluation to improve processes and empower physicians in providing primary prevention and healthcare services.44
Community engagement
The literature is in line with our observation regarding the imperative of involving communities in healthcare dialogues, as community members can offer substantial contributions to health initiatives. Engaging community health professionals from within the communities they serve has proven instrumental in fostering positive interpersonal connections between healthcare providers and clients at the PHC level. Nevertheless, it is noted that healthcare educational platforms aimed at empowering communities are deficient in Iran.42 Overall, the findings have underscored the significant role of communities in enhancing the readiness of primary healthcare systems for crises.
To enhance community engagement in primary healthcare in Iran, multiple strategies have been proposed:
Involving the community in all stages of curriculum design, implementation and evaluation.45 46
Integrating social accountability into the curriculum’s mission and goals.45 46
Establishing a multi-specialised curriculum committee.45 46
Fostering a culture of social accountability.45 46
Coordinating with primary healthcare centres.45 46
Engaging in community education; training faculty, family physicians, general practitioners and primary healthcare staff to teach community-related topics.45 46
Involving health promotion professionals in education.45 46
Assessing public input in health policy.45 46
Recommending interventions and policy options to promote public engagement.45 46
Implications
Our study offered significant implications for healthcare policymakers, administrators and researchers in Iran and other countries with similar contexts. The findings suggested the need to revise healthcare financing, redefine education and research, overhaul the primary healthcare system, develop new models for the family medicine programme, and increase community engagement in primary healthcare services. These findings can serve as primary inputs for future research to explore the strategies and effects of each implication in detail.
Conclusions
The findings of the study were categorised into five major themes: revision of healthcare financing, redefining education and research in primary healthcare, redefinition of primary healthcare, development of a new model for family medicine, and community engagement. Addressing vertical inequality in the Iranian healthcare system emerged as a significant implication. Proposed strategies included addressing deficiencies in knowledge and skills among family physicians, decentralising the decision-making process, empowering family physicians, and involving the community in healthcare planning and evaluation. Further empirical research is necessary to explore each finding in greater detail.
Data availability statement
Data are available upon reasonable request. The data of the research are available through making contact with the corresponding author.
Ethics statements
Patient consent for publication
Ethics approval
The research was approved by the ethical committee of Shiraz University of Medical Sciences (Ethical code: IR.SUMS.1399.1038). Participants gave informed consent to participate in the study before taking part.
References
Footnotes
Contributors MM conducted the data gathering, with RI validating the process. RI then conducted the data analysis, which was validated by MM. MS contributed to both data gathering and analysis. MK wrote the discussion section and revised the manuscript. The guarantor is RI. Bing AI chatbot was used in order to rewrite the text of the manuscript in terms of grammar and wording.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.