The agenda-setting process for urban family physician program within Iran's health insurance

Since 2005, health policymakers in Iran have focused on the rural family physician plan to minimize unnecessary specialist referrals and enhance both efficiency and equitable access to services. In September 2021, the urban family physician plan was launched, engaging various organizations, including insurance companies. A trustee was appointed to manage the implementation of the Iranian health insurance program. This study examines how Iran Health Insurance prioritized the urban family physician program on its agenda by applying Kingdon's agenda-setting model.

This descriptive qualitative study gathered data through semi-structured interviews with 13 stakeholders in Iran's urban family physician program, including planners, policymakers, and implementers. Purposive sampling, followed by snowball sampling, was used until data saturation was reached. Directed content analysis was applied, guided by Kingdon's multiple streams framework.

Three themes emerged: problem, policy, and political streams. The problem stream for Iran's family physician plan included structural challenges (such as incomplete implementation, physician shortages, fragmented health data systems, poor stakeholder coordination), social-cultural barriers (including low public awareness, resistance to change), and economic issues (such as high treatment costs, inadequate insurance coverage). The policy stream proposed solutions such as electronic systems, standardized protocols, new technologies, expanded education, and improved physician working conditions. Strong government and parliamentary backing were identified as critical to addressing these challenges, emphasizing the need for sustained commitment and holistic strategies.

The WHO, Iranian Parliament, Ministry of Health, and health insurers can serve as policy entrepreneurs to advance the family physician program within Iran's health insurance system. The WHO can leverage global health data to emphasize Iran's healthcare challenges, while the Ministry of Health and insurers can pinpoint issues via national research. The Parliament can facilitate public voices to gather input from citizens and experts.