The family physician (FP) plan is an integrated plan for providing primary health care (PHC) to the citizens of Iran.¹⁾ The FP plan for the rural population of Iran was launched in 2005, and today, it covers all rural and urban areas with a population below 20,000. This plan has been successful in improving health indicators, including life expectancy and infant mortality rate. Subsequently, in 2011, the urban FP plan was implemented as a pilot program in two provinces: Fars and Mazandaran. Currently, all residents of these two provinces are covered by either the rural or urban FP plan.²⁾

Under the urban FP plan, a general practitioner (GP) provides health services package at the first level of the healthcare system. In addition, other health workers like nurses, public health professions, and midwiferies provide primary health and rehabilitation services for clients who are covered by the FP plan.³⁾ The team, which is headed by the GP, is responsible for population health, preventive, and PHC services, ensuring continuity of health services for the covered population and referral of patients to higher levels for necessary cases. Payments for FP services and other levels are made by insurance organizations, which are calculated on the basis of the proportion of covered population and service quality. Therefore, patients at the first level have access to services at low or no cost, and if referral to higher levels of care is needed, insurance organizations pay the major share of expenditures. However, if patients do not use the referral system, insurance organizations have no liability for payments.^4,5)

Prior to the implementation of the urban FP plan, the country experienced a surge in revenue from oil exports in the wake of growing oil prices. At the commencement of the plan, however, the country was abruptly faced with the United Nations economic sanctions. Furthermore, the general inflation rate, and therefore, the inflation rate in the healthcare sector increased in the country (nearly 30%). Currencies had a surprising increase during this period. For example, US dollars increased from 10,140 Iranian rials at the beginning of 2011 to 30,780 Iranian rials in the end of 2012.⁶⁾ The country was also experiencing an economic recession with increasing unemployment and bankruptcy of many factories, while the economic growth (gross domestic product growth rate) was near zero and sometimes became negative in these two years.⁷⁾ The percentage of out-of-pocket payments (OOP, as a % of total healthcare spending) varied between 50% and 52% at the beginning of the reform.⁸⁾ Imported drug prices increased suddenly because of decrease in Iranian rials, and the Ministry of Health budget was insufficient to buy these types of drugs.^9,10) Shortage of the drugs increased at it harmed vulnerable population.⁹⁾ The government through the administration of the Ministry of Health attempted to reduce OOP by using government resources for healthcare financing. In addition, health insurance companies did not have enough power to control healthcare quality and utilization.¹¹⁾

Fars province is one of the two provinces that experienced the pilot implementation of the FP plan. Fars ranked fourth in terms of provincial population with a total of 4,596,658 residents. Urbanization rate was estimated as 67.6% with 102 cities and the capital city is Shiraz, which has a population of 1,549,453 with its suburbs.¹²⁾ Fars is located in the south of Iran and its population consists of several ethnic groups, including Fars, Turk, Lor, Arab, and other minor groups. Fars has one of the largest medical universities in Iran and because of its modern public and private hospitals has become one of the most important centers for medical services in Iran. Consequently, this province served as a suitable setting for the implementation of the pilot FP program.¹²⁾

Each health reform must eliminate the financial barriers related to changes in payments for healthcare services. OOP is one of these financial barriers. High OOPs may result in less access to healthcare services, especially for the poor.^13,14,15) In addition, healthcare utilization must be distributed on the basis of the health of each person, not of income. Having a less unequal distribution of healthcare utilization is another goal of the FP plan.⁵⁾ In this study, we intend to examine whether the pilot urban FP plan has achieved these two goals in Fars and the effects of the urban FP plan on the healthcare utilization and OOP in the presence of economic instability. Furthermore, we attempt to analyze the changes in inequality in OOPs and healthcare utilization.

No changes in utilization and OOPs were observed after the urban FP program in Iran. In addition, inequality in utilization and OOPs was adverse in some types of utilization services. The main aim of the urban FP program was to decrease unnecessary costs and improve accessibility of health services. One of the major barriers to increased access to health services is related to financial concerns. After the implementation of FP program, OOP did not decrease, and therefore, healthcare access and utilization remained constant. The FP program is a useful plan, which is recommended by the World Health Organization (WHO) to improve universal access to healthcare services. Its useful effects have been proven worldwide. As defined by the WHO, family physician program contains comprehensive efforts not only in healthcare services but also in education and research.²¹⁾ The urban FP program of Iran was implemented in a time when the country was faced with a serious economic crisis, including high inflation rate, economic sanctions, decrease in government budget, and risk of investment.⁷⁾ In such conditions, the Ministry of Health did not have enough budget to provide the necessary infrastructure for the FP program and it was only limited to the referral system. To have an efficient FP program, provision of infrastructure for the plan is necessary, including an efficient electronic health information system, in-service training of physicians, universal health insurances, focus on outcomes, quality measurement, and constant financing of the program.^22,23,24) Although, some of these factors, such as the universal health insurance system, have been implemented recently, no attempts have been observed for other reforms in the healthcare system to provide the country with the necessary infrastructure for the urban FP plan.

In addition, during high inflation, the purchasing power of the poor would decrease because of a decline in real income. Consequently, even though the prices of health services did not change, households might decrease their healthcare utilization. Furthermore, the side effects of inflation are more for the poor compared to the rich. Thus, inequality in utilization of services would change in favor of the pro-rich population.^25,26)

Another problem in the implementation of the urban FP program was the price of drugs. People were able to buy cheap drugs out of the referral system and were able to pay for them. In some cases, if the physician refused to prescribe a drug considered by the patient, the patient was able to turn round the referral system and buy cheap drugs independently. This phenomenon was applicable to specialists' visit as well.²⁷⁾ Furthermore, as discussed before, economic sanctions lead to an increase in the price of imported drugs. Thus, access to these types of drug, which are sometimes vital for vulnerable groups, decreased.^9,28) For example, a study in Fars has shown that access to thalassemia and hemophilia drugs in Iran decreased dramatically during the sanction period.²⁹⁾ Some types of these drugs were produced in Iran, but they were not as efficient as imported drugs; consequently, an increase in mortality in some chronic diseases like end-stage cancer patients was observed.^9,30)

The urban FP plan was implemented without any reforms in health insurance. Estimations had shown that at the time of implementation of the plan, nearly 14% Iranians were not covered by health insurance. Most of these people had low socioeconomic conditions and did not have access to cheaper healthcare services. However, in the recent reform of the healthcare system, health insurance coverage increased to nearly 98%.³¹⁾

The GPs of Iran are not trained for the FP program. They lack innovation in improving healthcare and their education is focused solely on treatment. There are no efforts to change the contents of medical education. To be prepared for the FP program, no in-services courses were provided for the practitioners. This might be a reason for constant OOPs during the period. However, the effects of improvement in health would not appear after one or two years.²⁷⁾ Iran's Ministry of Health must take efforts to prepare physicians for working in FP programs. Many countries have undertaken such efforts in this direction.^23,32,33)

Many similar studies showed that in the presence of economic crisis, the FP program might not achieve its goals. For example, Schwarz et al.³⁴⁾ found that OOP payments increased in the period of rural FP program in Tajikistan. Similar to Iran, Tajikistan experienced inflation during the FP program implementation. Drug expenditures had the highest increasing rate and doubled during the period. Furthermore, informal payments had not been increased after the implementation of family medicine program.³⁴⁾ Erus and Aktakke³⁵⁾ tested the effects of Turkey's health reform in 2003 on OOPs and showed that the share and level of OOP decreased after the reform. This reform contained both the family practitioner program and health insurance reform, and the country experienced economic stability during its health reform period.³⁵⁾ Evaluating Iran's rural FP program in Fars province (which was implemented during a stable economic condition) showed that not only the costs decreased, but also the healthcare utilization increased.³⁶⁾ Other evidence indicated that the FP program was successful and increased the health of the population.^22,37,38)

This study has some limitations. First, data for additional years after the urban FP program was combined with a new reform named the health evolution program. If we add other years in the study, it is difficult to investigate the sole effects of the urban FP program. Furthermore, we were not able to adjust the effects of this new reform at the household level. Second, some other potential confounding variables, such as quality of life, might be different between the two groups; however, because of the use of household income and expenditures survey, data on other variables were not available. Future research must investigate other reforms of Iran, such as the health evolution program and rural FP program.

In conclusion, after the implementation of Iran's FP program, inequality has increased in favor of the rich. OOPs did not change during the implementation of the program. The FP program is recommended by the WHO for improving universal access to health care services. However, this program was implemented in Iran at a time when the country was experiencing high inflation, economic recession, and United Nations sanctions. It is suggested to implement some changes, such as training the physicians, to increase the effectiveness and benefits of the FP program.