Challenges in second level of referral system in family physician plan: A qualitative research

family physician plan is one of the most important methods of improving access and equitable utilization of the health services. Implementing the referral system in this plan ensures proper utilization of health and hospital services. However, evidence suggests that the salient weakness of family physician plan is the failure of referral system. This study aims to identify existing challenges in implementing second level of referral system in family physician plan. Data were collected through semi-structured interviews.A purposive sample was identified according to predefined criteria. Data analysis was conducted using stages of framework analysis.According to a thematic framework, themes were set and key issues were identified. Twenty two semi structured interviews were conducted.Four themes and thirty four subthemes describing challenges of the second level of the referral system in family physician plan were identified: challenges related to units or employees of second level of referral system, to units or employees of the first level of referral system, to management and to general public. Several factors influence referral system quality,especially at the second level, which are mutually in a cause and effect order. Therefore, any effort to improve the quality of the referral system at this level requires systematic and coordinated actions based on a deep understanding of obstacles and challenges.