Barriers and challenges of establishing family physician policy for urban population; evidence from a qualitative study in Iran

Background. Family physicians play a crucial role in healthcare delivery systems worldwide. In Iran, the family physician program has been introduced in only two provinces, with its expansion to other regions currently stalled due to various challenges. This study aims to identify the barriers and challenges hindering the effective implementation of the family physician program in urban areas of Iran. Methods. This qualitative study utilized purposeful sampling to select health system policymakers, senior administrators, and physicians as participants. Data were collected through semi‑ structured interviews with 32 participants until saturation was reached. The data were analyzed using grounded theory, involv‑ ing open, axial, and selective coding to identify key themes and sub‑themes. Results. The primary challenge in implementing the urban family physician program was conflicting interests among stakeholders, identified as the core category. Key contributing factors included payment mechanism complexities, stewardship, structural issues, financial constraints, and cultural elements. Specialist physi‑ cians, in particular, resisted the program’s implementation, often employing reverse referral as a coping strategy. These challenges collectively hindered the nationwide rollout of the program. Conclusions. Addressing the barriers to implementing urban family physician policies requires a comprehensive reassessment of stakeholder roles and a restructuring of the payment system. Additionally, proactive efforts to resolve the complex contextual challenges within the healthcare system are essential for the suc‑ cessful implementation of these policies.