By Dr. Ebrahim Noori Goushki, Family Medicine Specialist.

The family medicine program is one of the important issues that, if implemented, will greatly reduce the burden of disease and the costs to families and the health system.

From the point of view of the World Health Organization; Family medicine is the center of global efforts to improve quality, cost-effectiveness, and equity in the health system. Family medicine is a global strategy that has been defined to solve the problems of the health field to lead to justice in health by transforming the treatment-oriented system into a health-oriented system. Family medicine aims to reform the health economy and reduce the confusion of patients and medical redundancies by governing a single system. In the family doctor plan, health care is defined as the focus of the doctor's activities. The overall goal of the plan is to maintain and improve the health of the community and provide health services regardless of age, gender, race, ethnicity, etc.

The family doctor program was gradually introduced in Iran's health system in 2001. The implementation of the family doctor plan in Iran started in villages and cities with less than 20,000 people in 2005, and in fact, it has been the most important reform in the health service delivery system of Iran in more than a decade. This plan was established with a series of changes in the three provinces of Sistan and Baluchestan, Chaharmahal and Bakhtiari, and Khuzestan in 2009 based on the version known as 01. With some changes, the implementation of version 02 was announced to the three provinces of Fars, Mazandaran, and Sistan and Baluchistan, and the implementation preparations were made. It was also prepared in Tehran and Shahid Beheshti universities, but finally, it was limited to the two provinces of Fars and Mazandaran. Now, after more than two decades of the family doctor strategy, the Iranian health system has not been able to implement family medicine.

The underlying reason for the non-implementation of family medicine is that our health system is somehow sick and we must do something about it before it's too late. We have to diagnose his disease on time and treat him properly, otherwise, his condition will get worse.

Almost most of the health elites believe that Iran's health system is plagued by challenges that if not treated with all the efforts of the country's health and treatment system, will eventually lead to its collapse. The difference of opinion of the elites is only in the cause of the disease and its treatment method. On the one hand, some say that the cause of these challenges is the complete lack of compliance with policymaking at the macro level, while others say that the cause of these diseases is the lack of adherence and commitment of ministers and governments to the promulgated laws, and some others say that the lack of proper use of elites and It is a technical expert. Some consider pinning this plan to titles such as referral systems and electronic health records as the most important challenge of not implementing family medicine. Honestly, all of us, from those in power and outside of power (with our behavior, our thoughts, our moral and spiritual characteristics, and our lack of skills and structures...), each of us has had a small or large contribution to this current health situation. Therefore, we will not enter into the analysis of the causes of health system diseases. We just want to show the signs and dangers in the health system and the need to do something before its too late, and then propose a solution to change this situation, which I think is the only low-cost, rational, and possible solution.

It seems that the country's health structure, that is, the existing structure, is not able to contain its internal crises in the current situation. In these years, this structure has consumed a part of the resources of the health field, and of course, the great services it has had in reducing or controlling the burden of diseases and medical advances, etc., all of which deserve appreciation. Here, we are not going to talk about the positive things, but we are going to explain the consequences of not implementing one of the important health priorities, which is a global strategy to overcome the crisis of the health system, which is family medicine.

The health system, with all the efforts made, has achieved this as we see. The best assessment of the performance of this system is the development laws of the country, many of its goals in the field of health have not yet been achieved to a large extent, and in some cases, we even went back, and in the field of family medicine, we almost did not take any basic and basic measures. That too, is the changing conditions in the world, where advanced countries are moving rapidly in the path of family medicine and its development. So, there must have been a fundamental problem in the work, that despite all these efforts and spending material and spiritual resources of these people, our achievements have been a series of chronic crises.

Who or what group is to blame for this situation that we have created for the health system and we have not yet been able to implement family medicine in the country? People? Families? Government? MPs? Health policymakers? Or …

  At the moment, we are not looking for the culprit, because after more than 20 years of promulgated laws and non-implementation of family medicine, we don't even have enough time, energy, and resources to find the culprit. We want to leave it and just think about the solution and talk about it. To ask ourselves, where should we start? Who should take the initiative to start stopping this process and change this situation? What is the sign of this advancement? What preparations should be made to accept that the health system has taken a step forward for change? Who or those institutions have the ability and are more worthy to start the process of change and reform in the health system? Do we have the requirements for the nationalization of family medicine and the referral system? Do we have enough trained family doctors to practice family medicine? Are there enough educational units for training family doctors and health teams? If it does not exist; has the necessary planning been done in this case? Have we drawn the road map correctly? Are we going to train family medicine specialists with the same current educational facilities? Do we use trained family medicine specialists? Do we have a stable institution at the head of the government for implementation? Have we done enough culture-building in this field? Have we combined insurance funds? Where is the institution that should implement the family medical system and its preparations to make changes in the country? Can governments that change every 4 years and health ministers who sometimes get a vote of confidence from the parliament one or two days before they become health ministers and did not know that they will become ministers, can they have a plan for the health system? Is it possible to have a plan without a team and continuous work for several years? Is it possible to find the answers to these questions? And to find the answers to these questions, do we even know rational and specialized dialogue? Do we know the difference between dialogue, criticism, discount, and destruction? And if we know, can we comply? When we discuss family medicine, do we put all the supporters and critics together around the same table? Do we accept the words of the critics? Have we used global experiences? Did we localize these experiences? Have we justified the specialists and sub-specialists of the country? Did we solve the issue of conflict of interest?

Now we all stick our heads out of our windows and tell the other you've made a mistake, you've got to go back, and no one goes back. In the meantime, what suffers and has seen are these people, who have come to hope and are stuck behind the knotted intersection, which the elites have created from all sides, and they have no way back, no way forward. The staggering payment of medical services from people's pockets, unnecessary imaging, unnecessary tests, confusion in the offices of specialist and sub-specialist doctors, and other words, the confusion of people in the referral system, has made our situation worse. But what is the root of this situation?

Now let's pay attention to the fact that if this management system could work better than this, at least it would have been able to achieve the goals of implementing the family medicine program. That is, despite all the facilities that have been available for years, a large part of the priorities of the health system has remained unfinished. This is not necessarily due to the stubbornness of reformist governments with fundamentalists. It is not due to the lack of financial resources to support those goals. It is not caused by the inherent evil of executives at executive levels. It is not caused by people's resistance or opposition. Rather, most of all, it is caused by the emptying of the country's health management system, from the collective wisdom of the elites and experts and technology owners, the refusal to accept the compassionate suggestions of critics, the reduction of people's trust and participation in the health field, and the lack of a stable system or institution at the top of power. , to implement the family medicine program.

Now the question is whether the management system and the current structure of the health system, which has not even been able to achieve the country's development priorities in family medicine, can achieve its other goals? And again, one can ask, in this case, can this current management system manage the crises that have come in the field of health, or does it ignore them like in previous years? It seems he can neither ignore nor manage these anymore. There is only one way: carrying out structural reforms to use the maximum participation of elites and critics and meritocracy, by launching a coherent and stable system in the structure of the country's health management system.

These structural reforms in the health system are more of a change in laws and procedures that do not require financial resources. It is a big decision that, if it is taken correctly, there is no other management authority that can stop it.

In any case, the decision to implement some structural reforms in the health management of the country is the last chance to get out of the current crisis of the health system and implement the full-scale family medicine and referral system, from the path of no return, in which the health system of our country has fallen.

If we want to look more closely at the issue of family medicine, we should also consider the following:

1- Make the tariffs realistic, when the tariff of a visit of a specialist and sub-specialist is not much different from the tariff of a first-level doctor and there is easy access to receive services directly from specialized levels; it is obvious that a program is not executed and cannot be executed.

People freely receive their services from specialized levels, there are induced demands, people's confusion is still there, and people's out-of-pocket payments are increasing, and so on.

2- Determine incentive packages for specialists and sub-specialists, when they perform medical procedures based on the policies and clinical guidelines developed by the Ministry of Health. By doing this, they are supported and the benefit reaches the doctor and the people. With this action, we reduce the crowding of medical offices and medical centers, and the specialist doctor provides his services with a real tariff with fewer patients and more easily.

3- Let people be free to choose their family doctor and not limit them.

4- Carry out culture building to increase the literacy level of society and change the attitude widely with the cooperation of relevant organizations. As much as we can inform the doctors the health care staff and the public.

5- Consider the medical potential of the country. We should have a correct opinion from experienced family doctors and health care staff. And let's use doctors, midwives, nurses, paramedics, and private health care staff. And, let everyone participate in the implementation of the program, not just limited to the public sector and its human resources.

6- Collect the insurance funds. So that the credits and financial resources of the program are estimated and provided by a certain source and authority.

7- According to the number of doctors and other human resources needed, we should provide the necessary platform for their education and training.

8- By changing the existing reforms and procedures, guarantee legal and policy support through the stable institution that was mentioned earlier.

I congratulate all family doctors, family medicine specialists, professors, and elites of family medicine on this valuable international day.

Keywords: family medicine, Dr. Ebrahim Noori Goushki, health system crisis, lack of collective wisdom, meritocracy, health management, Republic Islamic of Iran.