The role of external factors in shaping the supply and demand of general practitioners in Iran: a qualitative study

General practitioners are crucial for community health, but their numbers and distribution in Iran face challenges due to factors outside the healthcare system. In Iran-as in many health systems experiencing epidemiologic transition, fiscal constraints, and specialist-oriented care-primary care capacity is a key determinant of equity, access, and cost containment. Yet, evidence on how extra-system (external) forces shape the GP labour market remains fragmented, limiting actionable workforce planning. This study addresses that gap by synthesising a systematic framework of external drivers to inform policy design, prioritisation, and system dynamics modelling of GP supply-demand management. A qualitative approach using conventional content analysis was employed. Twenty-nine key individuals and experts from Iran's health system, medical universities, the Ministry of Health, and the Medical Council were interviewed to gather data on factors affecting GP supply and demand. Purposive and snowball sampling methods were used to select participants with relevant managerial, executive, or research experience. Six main categories of external factors were identified: social, political, technological, environmental, value-based, and economic. Social factors include demographic changes, social status of GPs, and job conditions. Political factors involve government policies, power dynamics, and political legitimacy. Technological factors encompass the impact of the internet, artificial intelligence, and medical equipment. Environmental factors relate to crisis preparedness and climate conditions. Economic factors include economic growth, inflation, and household income. Value-based factors cover cultural and family values and social perspectives on healthcare. Our framework explains how these external drivers interact across supply (entry, retention, geographic distribution) and demand (care-seeking, trust, affordability) pathways, offering concrete levers for policymakers to rebalance GP availability and utilization. Findings can guide targeted incentives, regulatory alignment, and technology-enabled primary care access to strengthen Iran's GP workforce performance and population health outcomes.