Challenges of the Referral System in Family Medicine Program in Iran: A Scoping Review

Background: Since its inception in 2005, Iran’s Family Medicine Program has faced persistent challenges in implementing an effective referral system, limiting its potential to optimize healthcare delivery and reduce hospital overcrowding. This scoping review synthesized evidence from 31 studies (2005–2022) to identify and categorize systemic challenges within Iran’s referral system. Methods: In 2023, a systematic search of English and Persian databases (e.g., PubMed, SID, Magiran) identified studies on referral system challenges. Data were thematically analyzed and mapped to six WHO domains: governance, financing, human resources, equipment, information systems, and service delivery. Results: Key challenges include: Governance: Fragmented policies, weak oversight and lack of enforceable referral protocols. Financing: Delayed payments to physicians and restrictive insurance tariffs disincentivize compliance. Service Delivery: Public distrust in family physicians, low reverse referral rates, and poor specialist feedback. Technology: Reliance on paper-based referrals and fragmented electronic records. Human Resources: Rural specialist shortages (0.5 per 10,000 in Iran vs. 4.2 in urban areas) drive bypassing of primary care. Conclusion: Iran’s referral system struggles reflect systemic deficiencies in governance, financing, and infrastructure. Successful reforms require multi-level interventions: digitizing referrals, incentivizing compliance through blended payment models, and rebuilding public trust via awareness campaigns. Lessons from countries like South Korea (differential copayments) and the UK (Shared Care models) highlight pathways for integration. Without urgent action, the Family Medicine Program risks perpetuating inefficiencies and inequities in Iran’s healthcare system.