Exploring the challenges of a pilot dental services payment initiative: a qualitative policy analysis at an Iranian dental school

BACKGROUND: Payment initiative in dental services is a key policy strategy to enhance access, affordability, and patient satisfaction. The Ghasedak project, a six-month pilot initiative at a university dental school in Iran, aimed to test a new payment model. This study analyzed the reasons for its suspension to draw lessons for future initiatives. METHODS: A qualitative study was conducted using Walt and Gilson's policy triangle framework. Data were collected in 2024 through 19 semi-structured interviews with project stakeholders (founders, managers, providers, and philanthropists) and 28 patients, selected via purposive sampling at Alborz University of Medical Sciences, Karaj. Data were analyzed using the Elo and Kyngäs inductive content analysis approach in MAXQDA, consisting of preparation, organization, and reporting phases. RESULTS: From 145 initial codes, 13 themes and 61 subthemes were identified. Mapped to the policy triangle, barriers included: Context (management instability, lack of institutionalized inter-sectoral cooperation, insufficient upstream support); Content (lack of an independent and transparent structure, unsustainable funding, non-adherence to social work principles, and lack of continuity in service delivery); Process (administrative bureaucracy, decreased financial transparency, lack of service support); Actors (low patient satisfaction stemming from mistrust, lack of motivation of stakeholders, and unrealistic patient expectations). CONCLUSIONS: Structural, managerial, and operational deficiencies undermined the pilot's sustainability and impact. Strengthening future payment initiatives requires secure financing, coherent management, streamlined implementation, and genuine stakeholder engagement. These findings provide actionable insights for policymakers seeking to design more resilient and effective dental payment initiative.