Exploring underlying factors associated with effective coverage of diabetes care in Iran: a systems thinking approach

Background: The prevalence of diabetes has been increasing in Iran; yet, effective glycemic control remains suboptimal. This study aimed to identify the underlying root causes that influence the effective coverage of diabetes care in Isfahan Province, Iran. Methods: We conducted a qualitative study based on face-to-face semi-structured interviews with twenty-nine participants, including fourteen health workers and fifteen patients with diabetes within primary healthcare (PHC) facilities in Isfahan Province, Iran. We conducted a thematic analysis and then mapped causal relationships through a causal loop diagram and characterized system archetypes, such as limits to growth and shifting the burden archetypes. Results: We identified four themes, namely, integrated, accessible, team-based, and continuous care capacities for diabetes management, along with their corresponding facilitators and barriers. Perceived facilitators such as the implementation of standard clinical guidelines like the IraPEN, the availability of electronic information systems such as the Integrated Primary Health Care System, known as SIB, the supply of essential medications and medical equipment, basic health insurance coverage, and screening, detection, and treatment adherence by healthcare workers, all improve the coverage of diabetes care. In contrast, perceived barriers such as weak infrastructure, poor coordination across healthcare providers and between levels of care, pharmaceutical expenditures, healthcare worker shortages, task diversification and workload, time constraints of healthcare workers, and inadequate patient engagement limit effective coverage. Conclusions: Despite efforts to integrate diabetes care into the PHC context and the expansion of basic health insurance coverage, underlying constraints such as fragmented care delivery, limited accessibility, and insufficient team-based and poor continuous care continue to impede the effective coverage of diabetes care in Iran. Our findings suggest that strengthening infrastructure for integrated care within the PHC setting, enhancing financial protection for patients, particularly those with complications, recruiting adequately trained healthcare workers for diabetes care, and promoting patient engagement are essential for providing effective diabetes management.