Department of Public Health, School of Health, Shahrekord University of Medical Sciences, Shahrekord, Iran. , fadaei.n88@gmail.com
Keywords: Mandatory-service Physician, Family Medicine and Referral System, Physician Retention, Comprehensive Health Service Centers.
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The implementation of the family medicine program and the referral system has long been considered one of the strategic duties and the main focus of ensuring, maintaining, and improving the health level of the people in the higher-level documents, health policies, and programs of various Iranian governments [1]. The main objectives of the program are to promote equity, improve the referral system, and reduce costs. The family physician, as the first point of contact with the covered population, plays a central role; therefore, the continuous presence of a physician interested in primary healthcare is vital for the success of the program [2]. The World Health Organization's report shows that in countries like Brazil, Thailand, and Denmark, people-centered primary care models and family physicians have been able to facilitate access to health services. The experience of these countries indicates that the success of the programs depends on infrastructure and the retention of human resources [3].
The lack of and frequent turnover of physicians in comprehensive health service centers are some of the fundamental challenges at the primary level of services. The severity of the problem is influenced by various factors such as socio-economic status, type of center (urban or rural), distance to the county center, salary and benefits, living conditions, and management style [4]. This issue is not unique to Iran; in Canada, the main reasons for young doctors leaving the area include being away from family and friends (69%) and the lack of suitable job opportunities for their partners (34.5%) [5]. In Saudi Arabia, nearly 40% of primary healthcare physicians are inclined to leave their current centers, which is directly related to the quality of work life [6].
Rural centers and cities with populations under 20,000 usually have doctors; however, in larger cities, the centers either lack doctors or have disinterested, highly experienced physicians working part-time. Most of the doctors working in rural areas and cities with populations under 20,000 are service-mandatory plan members who leave their posts and are replaced after completing their term [2]. This situation is not in line with the philosophy of family medicine, which is based on continuity of care and a stable agent-patient relationship, and it jeopardizes the quality and continuity of care. The lack of continuity of care prevents the doctor from having sufficient knowledge of the patient's history, leading to repeated tests and diagnostic procedures. In areas where physician retention is low, the rate of avoidable hospitalizations is reported to be 19.9% higher than in areas with high retention [7].
The family physician leads the health team, but most of the service-mandatory physicians lack sufficient experience and are unfamiliar with the network system and health programs [2]. This lack of preparedness is due to inadequate pre-service training. Therefore, doctors become less involved in technical and operational issues, leading to unsupervised delegation of authority. The lack of technical and managerial skills leads to dissatisfaction among experienced staff, patient dissatisfaction, and a decrease in health indicators. Many doctors, after gaining experience and completing their commitments, due to personal and organizational reasons such as further education and higher income, are not inclined to continue in healthcare centers and make way for other doctors [8]. This cycle of instability makes health management and program implementation vulnerable. Frequent changes in physicians lead to instability in technical management and a decrease in the efficiency and effectiveness of the centers [1]. Non-specialized or managerial positions often attract some doctors who are interested in the family medicine program.
For rural communities and deprived areas, the high turnover of physicians is described as a costly problem; these communities are forced to continuously invest in recruitment and hiring programs, while their long-term success is limited [5]. The healthcare system incurs direct and indirect costs to attract and retain human resources. The cost of physician turnover includes training, service discontinuity, low quality, dissatisfaction among staff and service recipients, and a decrease in indicators [9]. Physician retention not only improves health outcomes but also serves as a vital tool for economic efficiency in the healthcare system by reducing unnecessary diagnostic tests, decreasing referrals to specialists, and preventing costly hospitalizations [3, 7]. A case study in Thailand shows that with the establishment of a sustainable primary care model, the catastrophic health costs decreased from 6.8% in 1996 to 2.8% in 2008 [3].
Managers and planners must adopt supportive strategies for the retention of physicians to ensure the success of the family medicine program [2]. These strategies should be localized and tailored to the conditions of each region [1]. Programs such as incentive packages and performance-based pay, improving working conditions, increasing salaries, and providing growth opportunities are beneficial [4, 10]. Attention to motivational factors, cultural aspects, and the creation of a supportive work environment is also necessary [11].
The challenge of the lack of continuity in the activities of first-level physicians is due to structural, educational, and motivational weaknesses; therefore, managers should shift from the model of "temporary human resource provision" to "developing and maintaining sustainable human resources." The presence of a doctor should become a stable and attractive career path, not a temporary commitment. To achieve this goal, it is essential to reform employment contracts, revise medical education with an emphasis on prevention and managerial skills, ensure timely and performance-based payments, and design regional support packages that include welfare, accommodation, and psychological-social support in underserved areas.
Declarations
Ethical considerations: Not applicable.
Funding: Not applicable.
Conflict of interest: There are no conflicts to declare.
Authors' contributions: N.F.D: Conceptualization, writing – review and editing, final approval.
Consent for publication: Not applicable.
Data availability: Not applicable.
AI declaration: Not applicable.
Acknowledgments: Not applicable.
The lack of and frequent turnover of physicians in comprehensive health service centers are some of the fundamental challenges at the primary level of services. The severity of the problem is influenced by various factors such as socio-economic status, type of center (urban or rural), distance to the county center, salary and benefits, living conditions, and management style [4]. This issue is not unique to Iran; in Canada, the main reasons for young doctors leaving the area include being away from family and friends (69%) and the lack of suitable job opportunities for their partners (34.5%) [5]. In Saudi Arabia, nearly 40% of primary healthcare physicians are inclined to leave their current centers, which is directly related to the quality of work life [6].
Rural centers and cities with populations under 20,000 usually have doctors; however, in larger cities, the centers either lack doctors or have disinterested, highly experienced physicians working part-time. Most of the doctors working in rural areas and cities with populations under 20,000 are service-mandatory plan members who leave their posts and are replaced after completing their term [2]. This situation is not in line with the philosophy of family medicine, which is based on continuity of care and a stable agent-patient relationship, and it jeopardizes the quality and continuity of care. The lack of continuity of care prevents the doctor from having sufficient knowledge of the patient's history, leading to repeated tests and diagnostic procedures. In areas where physician retention is low, the rate of avoidable hospitalizations is reported to be 19.9% higher than in areas with high retention [7].
The family physician leads the health team, but most of the service-mandatory physicians lack sufficient experience and are unfamiliar with the network system and health programs [2]. This lack of preparedness is due to inadequate pre-service training. Therefore, doctors become less involved in technical and operational issues, leading to unsupervised delegation of authority. The lack of technical and managerial skills leads to dissatisfaction among experienced staff, patient dissatisfaction, and a decrease in health indicators. Many doctors, after gaining experience and completing their commitments, due to personal and organizational reasons such as further education and higher income, are not inclined to continue in healthcare centers and make way for other doctors [8]. This cycle of instability makes health management and program implementation vulnerable. Frequent changes in physicians lead to instability in technical management and a decrease in the efficiency and effectiveness of the centers [1]. Non-specialized or managerial positions often attract some doctors who are interested in the family medicine program.
For rural communities and deprived areas, the high turnover of physicians is described as a costly problem; these communities are forced to continuously invest in recruitment and hiring programs, while their long-term success is limited [5]. The healthcare system incurs direct and indirect costs to attract and retain human resources. The cost of physician turnover includes training, service discontinuity, low quality, dissatisfaction among staff and service recipients, and a decrease in indicators [9]. Physician retention not only improves health outcomes but also serves as a vital tool for economic efficiency in the healthcare system by reducing unnecessary diagnostic tests, decreasing referrals to specialists, and preventing costly hospitalizations [3, 7]. A case study in Thailand shows that with the establishment of a sustainable primary care model, the catastrophic health costs decreased from 6.8% in 1996 to 2.8% in 2008 [3].
Managers and planners must adopt supportive strategies for the retention of physicians to ensure the success of the family medicine program [2]. These strategies should be localized and tailored to the conditions of each region [1]. Programs such as incentive packages and performance-based pay, improving working conditions, increasing salaries, and providing growth opportunities are beneficial [4, 10]. Attention to motivational factors, cultural aspects, and the creation of a supportive work environment is also necessary [11].
The challenge of the lack of continuity in the activities of first-level physicians is due to structural, educational, and motivational weaknesses; therefore, managers should shift from the model of "temporary human resource provision" to "developing and maintaining sustainable human resources." The presence of a doctor should become a stable and attractive career path, not a temporary commitment. To achieve this goal, it is essential to reform employment contracts, revise medical education with an emphasis on prevention and managerial skills, ensure timely and performance-based payments, and design regional support packages that include welfare, accommodation, and psychological-social support in underserved areas.
Declarations
Ethical considerations: Not applicable.
Funding: Not applicable.
Conflict of interest: There are no conflicts to declare.
Authors' contributions: N.F.D: Conceptualization, writing – review and editing, final approval.
Consent for publication: Not applicable.
Data availability: Not applicable.
AI declaration: Not applicable.
Acknowledgments: Not applicable.
Type of Study: Letter to Editor |
Subject:
Health Services Management
Received: 2026/03/2 | Accepted: 2026/06/5
Received: 2026/03/2 | Accepted: 2026/06/5
References
1. Mehrolhassani MH, Jahromi VK, Dehnavieh R, Iranmanesh M. Underlying factors and challenges of implementing the urban family physician program in Iran. BMC health services research. 2021;21(1):1336. doi: [DOI:10.1186/s12913-021-07367-3]
2. Shirjang A, Mahfoozpour S, Asl IM, Doshmangir L. Challenges and strategies of implementation rural family physician in iran: a qualitative study. Depiction of Health. 2020;11(1):62-73. doi:
https://doi.org/10.34172/doh.2020.07 [DOI:10.34172/DOH.2020.07]
3. World Health Organization. Regional Office for the Eastern Mediterranean. Conceptual and strategic approach to family practice: towards universal health coverage through family practice in the Eastern Mediterranean Region. World Health Organization. Regional Office for the Eastern Mediterranean. 2014 [cited 2016]. Available from: https://iris.who.int/handle/10665/250529.
4. Pouraghasi L, Manavi S, Foruzanfar F, Olyaeemanesh A. Achieving universal health coverage; implementation of the 'supporting physician retention in deprived areas' programme in Iran. BMJ Global Health. 2024;9(8). doi: [DOI:10.1136/bmjgh-2023-014951]
5. Anisimowicz Y, Miedema B, Easley J, Bowes AE. Factors influencing Family Medicine resident retention and newly graduated physicians' first practice location. Journal of New Brunswick Studies/Revue d'études sur le Nouveau-Brunswick. 2017;8. Available from: http://w3.stu.ca/stu/sites/jnbs
6. Trabulsi FA, Alqurashi MT, Alharbi RA, Alghamdi AS, Kinsara AF, Khairy AM. The relationship between quality of work Life and turnover intention of primary health care physician in Saudi Arabia 2024. The review of diabetic studies. 2024;86-95. doi: [DOI:10.70082/khd53480]
7. Knight JC, Mathews M, Aubrey-Bassler K. Relation between family physician retention and avoidable hospital admission in Newfoundland and Labrador: a population-based cross-sectional study. Canadian Medical Association Open Access Journal. 2017;5(4):E746-52. doi: [DOI:10.9778/cmajo.20170007]
8. Mohammadibakhsh R, Sohrabi R, Aghighi N, Alihosseini S, Behzadifar M, Martini M,Aryankhesal A. Barriers and challenges of establishing family physician policy for urban population; evidence from a qualitative study in Iran. Journal of preventive medicine and hygiene. 2024;65(3):E434. doi: [DOI:10.15167/2421 4248/jpmh2024.65.3.3346]
9. Heidarzadeh A, Hedayati B, Alvandi M, Rezaei M, Farrokhi B, Dadgaran I, Huntington MK, Sirous S, Mirkazemi R. Referral system challenges of the family physician program in Iran: a systematic review. Medical journal of the Islamic Republic of Iran. 2023;37:49. doi: [DOI:10.47176/mjiri.37.49]
10. Sogai D, Shikino K, Yamauchi K, Araki N, Katsuyama Y, Aoki S, Muroya Y, Miyamoto M, Kamata Y, Ito S. Influencing physician distribution through education: a qualitative study on retention in Japan's rural hospitals. BMC Medical Education. 2024;24(1):1147. doi: [DOI:10.1186/s12909-024-06135-1]
11. Moldestad M, Sayre G, Rinne S, Kaboli PJ, Reddy A, Sanders KM, Mao J, Henrikson NB, Sterling R, Nelson KM, Wong ES. Perspectives on training and working in the VHA: implications for primary care physician recruitment and retention. Academic Medicine. 2022;97(8):1175-83. doi: [DOI:10.1097/ACM.0000000000004619]
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