Journal of School of Public Health and

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Background and Aim: Good governance results in better health outcomes for the society thorugh improving health system performance. The governance of Iran health stsyem faces some challenges. Hence, this study aimed to propose and verify a model for strengthening Iranian health system governance.
Materials and Methods: This descriptive study was conducted in 2016 using the Delphi method. A health governance model with six dimentions including sturucture, communication, regulation, policy making and planning, stewardship and evaluation and accreditation has been proposed. Then, the proposed model verified using 25 Iranian healthcare experts’ opinions in two rounds.
Results: Developing an integrated health system model comprising health system enablers and results, downsizing and reducing the number of directorates in ministry of health,determining basic principles for regulation, enhancing communication with other external organizations affecting people health, using more evidence in policy making and planning, developing a strategic plan and national health policy, enhancing leadership, management and stewardship; and developing comprehensive systemic standards for evaluation and accreditation of healthcare organizations are recommended to enhance the effectiveness and efficiency of Iran health system governance.
Conclusion: Iran health system governance faces numerous challenges. Using successful countries’ experience and internal health care experts’ opinions help to reduce the current challenges and achieve health system goals.
 

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Background and Aim: Man, as the Creator of God and the Creator of Creatures, has a right, one of which is the right to a healthy life, and this type of life can only be achieved through useful training. In this regard, comprehensive health education in schools is one of the most important pillars for the health of the next generation of the country. Therefore, the purpose of this study was to analyze the content of health components and promote the health of primary school books based on the assumptions of the health system with emphasis on education to increase the quality of primary school health.
Materials and Methods: In this descriptive study, content analysis method was used. The statistical population of this study was all second grade elementary school books of 2016-2017 (5 volumes). Statistical sample is equal to statistical population. The research tool was Shanon Entropy, which presents data processing in the context of content analysis in a new and quantitative way.
Results: The results of Shannon's entropy content analysis showed that the review of the 5 primary elementary second-level mental health books had the highest frequency with 236, and the least amount of disability with 10. The highest coefficient of importance among health components in elementary second grade was related to the components of nutrition health (0/21) and the lowest coefficient of prevention to high risk behaviors was (0/019).
Conclusion: Findings show that attention to each component of health education and health promotion is different; therefore, it can be concluded that some components of primary education textbooks pay less attention to some components of health education, while that health education and consequently health promotion is the most important factor in the advancement and guarantee of community survival. Designing, implementing, and managing health development programs is more than any other underlying concept such as health.

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Background and Aim: For achievement of equity in the population health the implementation of health in all policies is essential. The most crucial intervention in this approach is inter-sectoral collaboration.
 Materials and Methods: This was a qualitative study based on the national policy framework. Data were collected using literature review, in-depth interviews and focus group discussions with the stakeholders. The results were categorized into three sections, namely, situational analysis and factors affecting it, developing goals and objectives, and requirements and interventions.
 Results: Currently inter-sectoral collaboration in the Iranian health system potentially allows to have health in all policies policy in terms of explicit legislative support, national macro-policies/upstream documents and organizational structure. It will require proper planning as regards designing and institutionalizing appropriate mechanisms for collaboration, as well as cultural and skills capacity building, for stakeholders within and outside the health sector.
Conclusion: The findings of this study can be used in annual operational planning of the High Council of Health and Food Security secretariat.

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Background and Aim: It is essential to take action to strengthen the national primary health care (PHC) system. The purpose of this study was to conduct a comprehensive review to find ways to strengthen the PHC system in Iran based on the experiences of different countries.
Materials and Methods: This was a comprehensive review study. The relevant studies were retrieved using Science Direct, PubMed, Google Scholar, Scopus, Web of Science, Magiran, Iranmedex and SID databases. Inclusion criteria included all the studies that specifically focused on the factors enhancing the PHC system between 1998 and 2017. Finally, 30 articles were selected.
Results: Strategies for strengthening the PHC system were examined from two different angles: factors that facilitate the performance of the health care team, and ways to improve the implementation of PHC. In addition, strategies have been recommended for the following in order to strengthen the PHC system in Iran: trust-based relationships; widespread implementation of the National PHC Program with a focus on personnel training; teaching healthy lifestyle behaviors and drug side-effects; investing in information technology in the health sector in areas such as immunization, child care and prevention of chronic diseases.
Conclusion: Strengthening primary health care requires coordination and inter-sectoral collaboration; involvement and will of a wide range of health and non-health organizations; government support; strengthening of the referral system and the family physician; strengthening the health team; self-care and community participation; a public health-oriented and preventive approach in macro-policies; and, finally,  allocating more resources to the health sector.

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Background and Aim: The health system financing is the process of collecting, pooling and managing financial resources and purchasing healthcare services. Health financing plays an important role in achieving the health system goals and objectives specially universal health coverage. The aim of this study was to strategically analyze the Iranian health financing system and recommend strategies to strengthen it.
Materials and Methods: Using the scoping review method, all published studies about the strengths, weaknesses, opportunities and threats of the Iranian health financing system were searched in eight databases including "PubMed", "Scopus", "Science Direct", "Embase", "ProQuest", "SID" and "Magiran", as well as the "National Database of Medical Science Theses" and two search engines, namely, "Google" and "Google scholar". Finally, 29 studies were selected and analyzed using the framework analysis method and MAXQDA software. 
Results: Extended health insurance coverage, reduced out-of-pocket payments following the national health transformation plan, and increased healthcare tariffs were the strengths of the Iranian health financing system. On the other hand, regressive financing, high out-of-pocket payments and increased number of health insurance companies were the weaknesses of Iran’s health financing system. Political sanctions, financial crises and increased healthcare demands were the threats, while supportive laws, the NGO’s financial support, increased number of health care organizations and modern technologies were among the important opportunities for the Iranian health financing system. Increasing the health system financial resources through prepayments, structural and policy unification of health insurance system, health service tariff reform and enhancing health system efficiency and healthcare services quality are essential to strengthen the Iranian health financing system.
Conclusion: The Iranian health financing system is not resilient and faces several challenges. The health system policy-makers and senior managers should adopt the recommended strategies to strengthen the national health financing system.

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Background and Aim: The realist review has been introduced to review and synthesize the evidence related to the implementation of complex healthcare interventions. This method interprets the results of an intervention by explaining the causal relationships between the intervention and the results. This study aimed to explain the methodology of realist review in the health system.
Materials and Methods: This study was conducted using the scoping review. The following databases were used to find articles using appropriate search strategies and relevant key words: Pubmed, Scopus, Science Direct, and Embase electronic databases, as well as Google Scholar and Google search engines. Finally 49 articles were selected (in the period between January 1990 and December 2020) for review.
Results: The realist review is a theory-based approach to synthesize evidence related to the complex interventions, explaining the reasons for the successes or failures of interventions based on the causal relationships between the interventions, contexts, mechanisms and outcomes. A protocol was introduced to conduct a realist review composed of three phases ─ explaining, development and correcting the intervention program theory ─ and including seven steps of determining research questions; explaining the initial program theory; developing search strategies; collecting, evaluating and selecting evidence; synthesizing evidence; modifying the initial theory; and making suggestions. In addition, the structure of a realist review article was described and a checklist for evaluation of a realist review study was introduced.
Conclusion: The realist review is a suitable method for reviewing the complex health system interventions, explaining how an intervention relates to the results obtained. A realist review explains how, under what conditions and for whom a health and therapeutic intervention works.

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Background and Aim: Internet addiction means excessive and unnecessary use of the Internet. The aim of this study was to investigate the role of brain-behavioral systems in Internet addiction among university students.
Materials and Methods: This was a descriptive and correlational research. The statistical population was all the students of Islamic Azad University, Karaj Branch in the academic year 1397-98. A sample of 162 students were selected, based on the Tabachnick & Fidell formula, using the multi-phase cluster sampling technic. The tools used to collect data were the harmful Internet use and the brain and behavioral system questionnaires.
Results: Based on the multivariate regression analysis, 66.7% of Internet addiction among the students could be explained by brain-behavioral systems.  Active avoidance and approach, as components of the behavioral activation system, could predict Internet addiction negatively, while passive avoidance and extinction, as components of the behavioral inhibition system, and fight and flight from the components of the fight/flight system, could predict Internet addiction positively.
Conclusion: Purposeful communication and information search (pleasant unconditional stimuli), tedium and constant logic dominating the internet environment (unpleasant unconditional stimuli) have their own conditional cues on the Internet that indicate the degree of susceptibility of brain-behavioral systems to internet addiction.

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Background and Aim:  The health financing system is the process of collecting, pooling and managing financial resources to purchase health services. Sustainable financing of the Iranian health system is crucial for achieving universal health coverage. The purpose of this study was to identify strategies for sustainable financing of the Iranian health system.
Materials and Methods:  This study was conducted using the scoping review in 2020. The following databases and search engines were searched systematically between 21.03.2002 and 21.09.2020 to find studies related to sustainable financing strategies for the Iranian health system: PubMed, Web of Science, Scopus and Embase, Magiran, Iranmedex and SID databases, and two search engines; i.e., "Google" and "Google scholar”. Finally, 47 studies were selected and analyzed using the MAXQDA software and the framework analysis method.
Results: A total of 40 strategies were identified for strengthening the sustainability of Iran's health financing system, which were grouped into three categories: collecting funds, pooling funds and purchasing health services. The most frequently cited strategies for sustainable financing of the Iranian health system were the following: increasing the health share of gross domestics product, expanding tax revenues, pre-payment methods of health financing, strengthening public-private partnership, increasing the efficiency of the health system, reducing health system costs, consolidating insurance funds, eliminating insurance overlaps, value-based health service tariffs, optimizing health services support packages, and fixed payment methods based on  the performance of the health service providers.
Conclusion: The Iran's health financing system must be strengthened in such a way as to make it possible to collect, pool and manage sufficient financial resources to be used to purchase health services for the people to ultimately ensure universal health coverage leading to the promotion of the public’s health.

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Background and Aim: The World Health Organization considers the implementation of the referral system to be a key step in improving the quality of services in health care systems. The purpose of this study was to explain the executive challenges of the electronic referral system in Golestan Province, Iran.
Materials and Methods: A qualitative study was conducted in Golestan Province, Iran in 2019 with a content analysis approach. The participants were family physicians, specialists, university staff managers, responsible health officers in the Offices of Deputy Ministers of Health, the General Directorate of Health Insurance, Department of Information Technology, Rural Health Network managers, health network managers and patients selected purposefully. Data were collected through semi-structured interviews and analyzed using the content analysis method.
Results: The main challenges of giving appointments to patients included the lack of time of family physicians, the irregular presence of specialists, difficulty in getting an appointment, and reverse referrals. As regards referrals and waiting times, the main challenges were found to be the lack of sufficient admissions following cancellation of the health insurance contract with the private sector, the delay of physicians in attending the health centers, long waiting times to be visited, and writing the feedback by the physicians. In addition, the main challenges of the visits and diagnosis included the short visiting times, the higher quality of the specialists' visits in the private sector, and the lack of clear guidelines. Finally, the main challenges as regards giving feedback were the reluctance and noncommitment of some specialists to provide feedback, as well as the low quality and lack of usability of the feedbacks given.
Conclusion: Based on the findings of this study, the following actions and measures may help improve the current situation as regards the current referral systems: allocating sustainable resources; allocating financial credits; designing and implementing a reward and punishment system; reforming the queuing system; empowering medical students; and equipping specialists with electronic pens for giving written feedback.

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Background and Aim: The Primary Health Care (PHC) system is the most comprehensive, equitable and efficient way to promote people's health and social welfare by providing preventive, curative, rehabilitative and palliatvie services in a place close to where people live and work. Iran's PHC system faces challenges that limit its effectiveness and efficiency. The aim of this study was to identify strategies to strengthen Iran's PHC system.
Materials and Methods: A realistic review method was used in this research. Published articles on strategies to strengthen the PHC system between 1978 and 2019 were searched in eight databases and Google scholar search engine. Finally, 29 articles were found to be eligible for inclusion in this study; framework analysis was done using the MAXQDA-10 software. 
Results: Twenty-nine strategies were identified for strengthening the PHC system. A well designed PHC system is one with the following characteristics: realistic goals and appropriate strategies  equipped with necessary resources, organized in multidisciplinary teams that provide comprehensive and quality health services (intervention program), with strong governance and leadership, financing, work force, equipment and medicines, information systems and robust health services delivery processes and well adpated to the external environment (context). Such a PHC system will increase healthcare providers’ satisfaction and commitment, as well as the  patients’ trust, participation and satisfaction (the mechanism) and, finally, promotes, restores, and maintains the people health (result).
Conclusion: A strong PHC system is a pre-requisite for strengthening a health system. Various strategies such as strengthening management and leadership, improving organizational structure and culture, improving the information system, empowering human resources and increasing population coverage can lead to an improved PHC system. Historical, social, cultural and economic factors affecting the health system should be considered in redesigning and stregtening a PHC system.
 

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Background and Aim: One of the complex processes in the Ministry of Health and Medical Education in Iran is the process of registering pharmaceutical supplies. Currently the registration process is a multi-stage process, resulting in parallel services, a waste of time and unnecessary expenses. Therefore, an integrated system will improve the relevant service delivery. The purpose of this study was to identify a set of activities that could be collectively considered as a single service to create an integrated system for registering pharmaceutical supplies in the Ministry of Health and Medical Education, Iran.
Materials and Methods: This was an applied research, beginning with collecting information about the registration processes for 20 different products. In order to identify the services/steps of an integrated system for recording pharmaceutical supplies, first the Gray-Wolf multi-objective optimization (GWO) algorithm was proposed. Then the values of the algorithm parameters were extracted by the goal-based requirements analysis method and the algorithm was implemented. Finally the best services were extracted by the hierarchical analysis process.
Results: Through the proposed algorithm seven services were identified, including product class inquiry, document registration, document review according to license type and product class, licensing, laboratory services, clinical studies and payment service. These services were carefully approved with a precision of 97.3 by the experts of the Ministry of Health. The proposed framework for recording drug requirements was found to be effective and could facilitate the process by up to 90%, reduce the processing time by 80% and reduce the processing costs by 65%.
Conclusion: Creating an integrated system for registering pharmaceutical supplies is one of the important challenges of the Ministry of Health and Medical Education. This can be achieved by identifying services and combining these services to create an integrated system.
 

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Background and Aim: Referral system is one of the principles and foundations of primary health care services. One of the most important challenges and problems of the referral system is the lack of knowledge of people and patients of its nature, services and benefits. The purpose of this study was to identify the factors affecting the acceptance of the referral system by patients.
Materials and Methods: This was a qualitative study conducted in 2021 using the framework (structural) analysis method. The participants were 18 experts in the field of referral system and 14 patients referred to the outpatient and inpatient wards of Imam Khomeini Hospital Complex in Tehran selected by purposive sampling. Data were collected by Semi-structured interviews and analyzed using the MAXQDA.
Results: Based on the findings in this study, Factors influencing the acceptance of the referral system by patients were found to be the following: (1). Factors related to the stewardship and governance of the health system (responsibility and accountability, appropriate levels of health services, patient-centered care, and rules and regulations); (2). Factors related to the health services access (financial, physical and cultural); (3). Factors related to service providers (trusting healthcare staff, professional skills of service providers, and their behavioral and communication skills); (4). Factors related to the service delivery process (quality of service delivery, attention to patients' wants and needs, use of technology in service delivery, monitoring service delivery, and service coverage); (5). factors related to the recipients of the services (satisfaction, education, awareness and communication).
Conclusion: Considering the importance and key role of patients in the success of the referral system, health planners and policy makers should pay special attention to the factors identified in this study.

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Background and Aim: Primary health care is a holistic approach that aims to maximize people's health and well-being as quickly as possible in their immediate living environment. The primary health care system is the first point of contact of the people with the health system. Therefore, increasing its resilience will play a significant role in controlling and managing pandemics. This research aimed to identify strategies to strengthen the resilience of the primary health care system in the Covid-19 pandemic.

Materials and Methods: This study was conducted using the scoping review method. Using appropriate keywords search was done on the subject of the study in PubMed, Web of Science, Scopus, SID, Iranmedex and Magiran databases and Google and Google Scholar search engines. Finally, after screening and reviewing the titles, abstracts and texts of the retrieved documents, 36 articles were selected and strategies to strengthen the resilience of the primary health care system in the Covid-19 pandemic were extracted from them.
Results: A total of 48 strategies/solutions were extracted to strengthen the resilience of the primary health care system, categorized into 6 groups, namely, governance and leadership, financing, human resources, medicines and equipment, health information systems, and health service delivery. Among the most frequently solutions mentioned were the following: Dynamic and accountable leadership, using valid research evidence in policy-making, contingency planning, increasing inter-sectoral cooperation, advocacy for health policies, community involvement, sustainable financing, recruiting additional staff and training and supporting them, providing sufficient stocks of medicines and diagnostic kits, developing and modernizing public health information systems, facilitating people's access to health centers, continuing to provide health services, and increasing the community’s health literacy.
Conclusion: The structural and process components of the primary health care system including "governance and leadership", "financing", "staff", "equipment, vaccines and medicines", "information" and "health care delivery" should be strengthened in a coordinated manner in the primary health care system to be prepared for future epidemics.
 

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Background and Aim: The health financing system is "the process of collecting, pooling and managing financial resources and purchasing healthcare services”. Iran's health financing system is facing challenges. The aim of this study was to evaluate the Iranian health financing system.        
Materials and Methods: This descriptive study retrospectively evaluated the health financing system of Iran between 2000 and 2019 using archival data. Data were collected from the World Bank website and analyzed using the Excel software.
Results: Iran's health expenditure per capita increased by 3.7% annually between 2000 and 2019 and reached $868 (purchasing power parity) in 2019. Iran's total health expenditure increased from $32 billion in 2000 to $72 billion (purchasing power parity) in 2019 (5.9% annual increase). Iran accounted for about 0.6% of the world total health expenditure in 2019. In that year about 6.7% of the country's gross domestic product was spent on health, the global average being 9.8%, while the general government health expenditure (% of the then current health expenditure) in Iran and the world were 49.5% and 59.8%, respectively. Out-of-pocket expenditure (% of the then current health expenditure) decreased in the last decade in Iran, reaching 39.5% in 2019, compared to 18% worldwide.
Conclusion: Iran’s health system costs are increasing at a faster rate than the growth of its Gross Domestic Product (GDP). The country’s health expenditure (% of GDP) and, as a result, the general government health expenditure (% of general government expenditures) has decreased and out-of-pocket expenditure (% of current health expenditures) has increased. Therefore, reforms should be implemented to strengthen the country's health financing system.
 

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Background and Aim:  The health, safety and environment (HSE) system is an integrated system that tries to create a healthy, pleasant and lively environment with no accidents, damages and injuries by converging and synergizing human resources, facilities and equipment. The purpose of the present study was to investigate the validation of the revised scale of HSE performance.
Materials and Methods: This was a descriptive and analytical research conducted using the psychometric method. The statistical population included all workers of the steel companies in Kerman Province, Iran in 1400. Using the cluster sampling method based on psychometric criteria a sample of 100 was selected for the convergent validity and a sample of 578 for the construct validity section. Data were collected through two scales of HSE performance and job stress (Cohen et al., 1983). Content validity, convergent validity and factor analysis methods were used to check the validity of the scale. The reliability of the scale was checked using the internal homogeneity and classification reliability (dividing in 2 haves).  The SPSS version 22 software was used for data analysis.
Results: Confirmatory factor analysis confirmed the six-factor model. The questionnaire was used along with the 35-item occupational stress questionnaire of Cohen et al. (1983) which had good reliability and validity. The alpha coefficient obtained for the whole scale was 0.79, and for the subscales as follows: resilience 0.93, demand 0.90, role 0.93, control 0.85, support 0.72 and relationships 79.0. In addition, the reliability coefficient of the scale was also calculated using the classification method. The classification coefficient for the first and second halves of the data was 0.87 and 0.62, respectively, the correlation between the two halves being 0.248. These findings indicated a favorable internal consistency coefficient for the HSE performance scale (P<0.001).
Conclusion: According to the findings obtained based on the HSE validation, which showed that the fit of the model is high and also that the evaluation of HSE performance has a great role in the health of employees, more attention should be paid to the establishment and implementation of HSE management in Kerman steel companies.
 

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Background and Aim: Health system financing is the process of collecting, pooling, and allocating financial resources to maintain, restore or promote the health of the people. Developing countries face many challenges in mobilizing, managing and allocating health financial resources. The aim of this study was to identify sustainable financing methods in developing countries.
Materials and Methods: This study was conducted using the scoping review. All the studies related to health system financing methods in developing countries were searched in the English electronic databases (i.e., Pubmed, Scopus, Science Direct, and Web of science), Persian electronic databases (i.e., Magiran, Iranmedex, and SID) and Google Scholar and Google search engines using appropriate keywords. Finally, 94 suitable documents were selected and analyzed using the framework analysis method and MAXQDA software.

Results: Forty-two methods were identified to strengthen the sustainability and resilience of the health financing system in developing countries; these methods were grouped into three categories: collection and management of financial resources, pooling of financial resources and purchasing of health services. The most frequently used solutions to strengthen the sustainability of the health financing system in developing countries were as follows: expanding social health insurance plans, integrating multiple health insurance plans, strengthening public-private partnerships, establishing a robust referral system, imposing taxes on harmful commodities, using perspective fixed payment methods, defining needs-based health service packages, promoting donors’ contributions, and reforming health service tariffs.

Conclusion: The health financing system in developing countries should be strengthened. The financial reforms of the health system should be accompanied by reforms in providing health services to make possible efficient and effective results. Health policymakers and senior managers should strengthen the governance of the health financing system at the macro level. In addition, healthcare managers should increase the efficiency and reduce resource wastage by strengthening budget capacity and financial management at the micro level.

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Background and Aim: Considering the destructive consequences of corruption in Iran’s healthcare system, the present study aimed to explain the roots and causes of corruption prevalence in this system.
Materials and Methods: This was a qualitative study with quantitative content analysis conducted in Iran’s Ministry of Health and Medical Education (MHME). Data were collected based on in-depth interviews with 13 experts in the MHME headquarters selected by theoretical and snowball sampling. The unit of analysis of the interviews was the sentence and the conducted interviews were analyzed through thematic analysis using the Shannon Entropy index.
Results: Data analysis showed that legislative fields with an importance coefficients (IC) of 0.293 ranked first, followed by social and cultural fields (IC 0.26), economic fields (IC 0.175), decision-making fields and organizational factors (IC 0.174), and, finally, individual factors and micro-level fields (IC 0.102).
Conclusion: Considering the importance coefficient of individual factors and micro-level fields,
it can be concluded that the personality and individual characteristics of the experts/relevant persons are less important in the corruption occurrence, while the legal, social and cultural variables paly crucial roles in explaining corruption in the Iran’s healthcare system.
 

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Background and Aim: So far various medicinal treatments have been introduced to treat obesity. In this study we compared the available drugs for the treatment of obesity in women with polycystic ovary syndrome (PCOS).
Materials and Methods: This study was conducted using systematic review and network meta-analysis (NMA) methods. The major international databases including PubMed, Web of Science, Scopus, Cochrane Library and Embase were searched, the search ending in March 2022. Only randomized controlled trials (RCTs) comparing medicinal interventions in women with PCOS were included in the study. Two of the researchers were responsible for screening the retrieved sources. The Cochrane tool was used to assess the risk of bias. The loop-specific and design by treatment interaction approaches were used to assess the consistency assumption. Treatments in each network were ranked using the P-score. The random effects model was used to report the results. The results were reported at %95 confidence interval (CI). I² statistic was used to check the heterogeneity of the studies.
Results: Out of the 9335 retrieved references, 9 studies met the eligibility criteria. There were two networks for the treatment of obesity in women with polycystic ovary syndrome: Liraglutide (1.2), [P-score=0.86, MD=-8.02(-20.99, 4.94)] as the best treatment in the first network, and Orlistat (120), [P-score=0.88, MD=-3.49 (-5.17, -1.81)] as the best treatment in the second network.
Conclusion: Based on the results of network meta-analysis, it seems that the best medicinal interventions for obesity in women with polycystic syndrome rare Liraglutide (1.2) and Orlistat (120).
 

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Background and Aim: The health system is trying to prevent unnecessary referrals to higher levels by providing tiered services and thus reduce the cost of health care. Therefore, this study was conducted in Zahedan City, Iran with the aim of finding the causes of referrals from level 1 to higher tiers in rural areas.
Materials and methods: This cross-sectional study was conducted on 458 rural patients referred to the second level in the rural areas of Zahedan City, Iran. Data were collected from the family health files available in the Sib system and analyzed using the SPSS-16 statistical software, the statistical tests being descriptive statistics (percentage, frequency) and Chi-square test.
Results: The highest (57.6%) and lowest (4.1%) proportions of referrals to the second level of service provision were found to have been in 2018 and 2016, respectively. From among the referred patients nearly 50% had been referred due to the need for a higher expertise, thus most referrals (67.2%) were to specialists. Further analysis of the data showed that only in 23.6% of the cases there was a feedback from the higher level to the first level.
Conclusion: The findings show that referrals from family physicians to higher levels in the health system requires higher medical expertise and patient insistence. In addition, feedback to the first level of service provision has not received proper attention. Establishing interactions between physicians and other health service levels, refresher training of physicians, emphasizing the importance of providing feedback and promoting the awareness of patients can reduce to a large extent inappropriate referrals.
 

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Background and Aim: Primary levels of health services are designed to provide, maintain and promote the health of healthy young people, while the goal of higher levels is to screen and restore the health of the patients. One of the challenges is the personal culture of some of the health service providers and the recipients of these services. One of the recent reforms in the healthcare system has been the implementation the Health System Reform Plan based on the family physician and the referral system. This study investigated the status of the referral system in the family physician program in Isfahan metropolitan area in 2018.
Materials and Methods: This was a qualitative study with a contractual content analysis conducted on a sample of 28 individuals selected by purposeful snowball sampling continued until saturation. Interviews were held with male and female healthcare workers (n = 14), midwives (n = 10), and managers (n = 4). Data analysis was done using the SPSS.25 statistical software.
Results: This study succeeded to explain strategies to improve the quality of the referral system and the views of health service personnel and, finally, find the strengths, weaknesses and solutions for improving the referral system.
Conclusion: The findings show that the performance of the referral system in the city of Isfahan is in line with the goals. However, visiting referred patients, providing feedback and referral to the laboratory are not as effective as they should be. Therefore, planning is needed to remove obstacles and solve problems such as shortage of human resources, non-human resources and infrastructure, insufficient provision of medicines and job insecurity so that goals can be reached.