Abstract
Background. One of the significant challenges facing the healthcare system in Iran is enhancing the efficiency of medical services and ensuring equity in access to care. The Family Physician Program and the Referral System are pivotal health policies within this context. This study aims to identify the key factors that drive the successful implementation of the Family Physician Program and the Referral System in Sistan and Baluchestan Province.
Methods. This applied study employed an exploratory mixed-methods design. The qualitative phase included 15 participants, such as university health administrators, family physicians, health policy experts, and faculty members, all with at least five years of managerial experience. In the quantitative phase, the population comprised all individuals who used services through the Family Physician Program and the Referral System. A sample of 384 respondents was determined using Morgan’s table. Data collection involved field and documentary methods. Semi-structured interviews were applied in the qualitative phase, while questionnaires were employed in the quantitative phase. Data were analyzed using the Delphi technique for the qualitative section and descriptive and inferential statistics for the quantitative section. The study was carried out in 2024.
Results. The results revealed that several driving forces- including the training and empowerment of family physicians and healthcare teams, public awareness and cultural sensitization, the provision of sustainable financial resources, and the establishment of adequate technical and informational infrastructure- are critical to the effective implementation of the Family Physician Program and the Referral System.
Conclusion. The proposed model demonstrates strong reliability in explaining the interrelationships among variables and highlights the adequacy of policy implementation quality in the Family Physician Program and the Referral System.
Extended Abstract
Background
The Family Physician and Referral System policy is a critical component of national healthcare reform, aiming to ensure equitable access, enhance service quality, and rationalize expenditures. Despite its vital objectives, this policy faces significant structural, operational, financial, and cultural challenges across various provinces. Sistan and Baluchestan Province, with its unique geographical, economic, and socio-cultural complexities, presents a particularly challenging context for effective policy implementation. This region consistently lags behind national health indicators, struggling with limited access to health centers, human resource shortages, and underdeveloped infrastructure. This study aims to systematically identify and empirically validate the key drivers for effective policy implementation within this complex provincial context, providing empirically grounded insights to guide strategic interventions and reduce health disparities.
Methods
This study employed a pragmatic mixed-methods exploratory design, integrating qualitative and quantitative methodologies. The research is applied, focusing on practical implications for policy implementation.
Qualitative Phase: Semi-structured interviews were conducted with 15 purposively sampled experts from the provincial health system and medical universities, each with a minimum of five years of relevant managerial or specialized experience. Qualitative data were rigorously analyzed using an iterative Delphi method to achieve robust consensus on critical implementation drivers. Components achieving at least 70% consensus were retained, leading to the conceptualization of five primary dimensions.
Quantitative Phase: Following qualitative insights, the quantitative phase targeted 384 beneficiaries of the Family Physician and Referral System in Sistan and Baluchestan Province. The sample size was determined using the Krejcie and Morgan table (1970). Data were collected via a meticulously designed 32-item Likert-scale questionnaire. Simple random sampling ensured sample representativeness.
Data Collection Tools and Validation: The questionnaire underwent rigorous validation, including face and content validity assessments through expert reviews. Lawshe's Content Validity Ratio (CVR) confirmed content validity. Reliability was established through Cronbach’s alpha and Composite Reliability (CR), with all values exceeding 0.7. Construct validity was assessed through confirmatory factor analysis, with factor loadings, Average Variance Extracted (AVE), and the Fornell-Larcker criterion confirming standard ranges.
Analysis Techniques: Qualitative data were analyzed using thematic content analysis and Delphi rounds. Quantitative data were subjected to descriptive and inferential statistical analysis using Smart PLS 3. Structural Equation Modeling (SEM) based on the Partial Least Squares (PLS) approach was employed to assess hypothesized relationships. Key statistical metrics included t-values, R-squared (R2), and the Stone-Geisser Q2 criterion to evaluate model fit and robustness.
Results
The study successfully identified and validated several critical drivers, demonstrating strong expert consensus and significant statistical influence on effective policy implementation:
Training and Empowerment of Healthcare Providers: Continuous and updated training programs for family physicians and healthcare teams are paramount. Such training achieves robust expert consensus (Kendall’s coefficient of 0.857), enhances technical competencies and improves interpersonal communication and cultural sensitivity.
Public Awareness and Cultural Adaptation: Initiatives disseminating information about the referral system's benefits significantly impacted community acceptance and utilization. Tailored public campaigns fostered positive engagement, increasing primary healthcare service utilization.
Infrastructure Development: Establishing resilient technical and informational infrastructures, including comprehensive electronic health records (EHR) and integrated communication networks, was a cornerstone for operational efficiency and seamless service delivery. High R2 values (0.781) underscored its profound influence.
Financial Sustainability: Consistent availability of stable and adequate financial resources emerged as a pivotal determinant for long-term policy viability and scalability. This was robustly supported by high statistical significance (P<0.001) across multiple indicators.
Inter-Organizational Coordination: Effective and synergistic collaboration among governmental and non-governmental entities was a crucial driver, particularly in resource-constrained environments. Enhanced coordination reduces redundancies, optimizes resource allocation, and ensures coherent service delivery.
Model Validation: The proposed structural model demonstrated exceptional statistical fit and predictive power. The Goodness-of-Fit Index (GOF) was 0.669, indicating strong overall model fit. All individual t-values for latent constructs exceeded 1.96, confirming robust reliability and validity. The Stone-Geisser Q2 value of 0.504 further corroborated the model’s substantial predictive relevance.
Conclusion
This research clearly highlights the need for a comprehensive, multi-faceted, and context-aware approach to implementing the Family Physician and Referral System policy in Sistan and Baluchestan Province. The study offers strong empirical evidence stressing the importance of integrating strategic initiatives across key areas: policy actions (training, public awareness), infrastructure development (EHR, telemedicine, facilities), financial models (sustainable funding), and collaboration frameworks (inter-sectoral partnerships). By effectively addressing these validated critical factors, policymakers and healthcare administrators can greatly improve health outcomes, reduce health disparities, and increase community satisfaction and trust. Future research should examine the long-term effects, scalability, and cost-effectiveness of these interventions in similar resource-limited settings. This study provides a foundational guide for creating adaptive policies that respond to the unique challenges of regions like Sistan and Baluchestan, supporting sustainable health system improvements and health equity.
Practical Implications of Research
The findings provide policymakers with actionable strategies for strengthening the Family Physician and Referral System. Prioritizing capacity building, public engagement, financial stability, and infrastructural development can improve patient satisfaction and system efficiency. Moreover, the validated drivers can be adapted to similar underserved regions, contributing to broader health equity.