Perceived and anticipated health system challenges to the implementation of effective case management in oncology palliative care in Iran: a qualitative study with Delphi expert consensus

Case management improves outcomes in palliative care for cancer patients; however, its implementation remains limited globally, and specific barriers hinder its adoption. Therefore, this study aims to identify perceived barriers and assess their importance and scientific acceptability through Delphi expert consensus. This multi-method study was conducted in Iran. The qualitative phase employed conventional content analysis of semi-structured interviews with 23 policymakers and healthcare providers selected through purposeful sampling. Data were analyzed using conventional content analysis of Graneheim and Lundman, and the Rigor of the data was evaluated using Lincoln & Guba criteria. The subsequent Delphi phase involved a panel of experts across four rounds to assess the importance and scientific acceptability of the identified barriers. The analysis revealed two main barrier categories: structural (6 categories) and process (4 categories). Structural barriers included a weak referral system, coordination challenges across settings, restricted patient records access, resource constraints, policymakers’ and providers’ resistance, and paternalistic healthcare culture. Process barriers encompassed interprofessional collaboration challenges, role ambiguity in case management, focus of palliative care on end-of-life care, and weakness in shared decision-making. All ten barriers met the predefined consensus criteria across four Delphi rounds, with no items eliminated; consensus was defined as a mean score ≥ 70% of the maximum score and SD ≤ 1.0. This study presents an expert consensus framework of multilevel barriers requiring attention to policymaking, infrastructure, and cultural factors, providing an evidence-based foundation for developing contextually appropriate case management models that can improve palliative care delivery for cancer patients.