Compulsory service program for healthcare workers: a qualitative driver analysis from ophthalmologists' perspectives

Compulsory service programs are used to improve access to health professionals in underserved areas. Their implementation depends on workforce conditions, organizational support, and the wider policy environment. Specialist services such as ophthalmology likewise rely on functioning clinical infrastructure, trained support staff, and referral capacity. This study aimed to identify the main factors and driving forces shaping the future of Iran's compulsory service program for healthcare workers in underserved areas, drawing on ophthalmologists' experiences and an expert-panel assessment.

A qualitative driver-analysis study was conducted. Environmental scanning drew on articles, books, media sources, and expert interviews. Eighteen ophthalmologists were interviewed using purposive sampling, with recruitment continuing until code saturation was reached. Interview data were analyzed using conventional qualitative content analysis, and the identified factors were subsequently organized using the PESTEL framework: political, economic, sociocultural, technological, environmental, and legal factors. A five-member expert panel identified the final driving forces qualitatively through discussion.

Eighteen ophthalmologists participated in the interviews: 13 (72.2%) were men, median age was 37.5 years (IQR, 35.0-42.8; range, 30-63), and 12 (66.7%) had personally worked in an underserved area. Responses on the principal challenge were categorized as financial for 10 participants (55.6%), management or implementation for seven (38.9%), and sociocultural for one (5.6%); 17 participants (94.4%) considered the program in need of redesign, and 13 (72.2%) stated they would be willing to serve in an underserved area if major problems were corrected. The expert panel identified 10 driving forces: national infrastructure development; welfare and financial support for the health workforce; international sanctions; service-recipient satisfaction; willingness of policymakers, legislators, and implementers to continue the program; political and social stability and security; social demand for free medical services; epidemics and emerging diseases; physicians' social satisfaction; and the national health profile, including population and disease patterns.

In this purposively selected ophthalmologist sample, financial and management or implementation problems were the most frequently categorized immediate challenges. The expert panel identified 10 driving forces spanning workforce conditions and broader political, social, and health-system factors. These driving forces should be regarded as expert-identified areas for policy review and future evaluation rather than as established causal determinants.