Atune and colleagues implied that using general physicians as gatekeepers could lead to increased considering accessibility to services, equity, improved physician-patient relationships, increased responsiveness of the healthcare staff, and improved effectiveness.9 The ratio of direct referral numbers to physician visits decreased from 0.85 in 2004 to 0.81 in 2006; however, this reduction is not significant and mainly indicates lack of improvements in our referral system. Gross and

co-workers found considering family physicians as gatekeepers for referral to specialists might result in improved management and coordination in patient care and also affect the cost control.18 Frank and Inhibitors,research,lifescience,medical Inhibitors,research,lifescience,medical colleagues concluded that an efficient referral system might lead to cost reduction and an inappropriate referral could damage the quality of care.19 Moreover, the referral per each visit by the doctor to the pharmacies increased from 0.5 in 2004 to 1.2 in 2006 and also the burden of referral to laboratories increased from 0.09 in 2004 to 0.22 in 2006. Although physicians are not Inhibitors,research,lifescience,medical allowed to prescribe more than 2-3 types of drugs per visit and order laboratory tests in more than 10% of all visits, it can yet increase the direct costs

of health. With respect to family health, a considerable increase was seen in pregnant women’s referrals from health houses by physicians (152.2%), gynecological care by obstetricians (190.5%) Inhibitors,research,lifescience,medical as well as pregnant women’s visits (70.11%), breast examinations (158.3%), insertion of intrauterine devices (16.14%), and pop smear requests (89.79%). This increase was because of adequate and proper access to obstetricians and establishment of necessary equipments and facilities. Yaghoobi and colleagues indicated that creating family planning files, providing necessary education, providing access for all people and giving Inhibitors,research,lifescience,medical the correct consultation to women by

health staff, could be the effective steps for accomplishment of population policies and fertility health plans.20 As mentioned earlier, the family physician plan in Iran was established to increase the efficiency and effectiveness of the health system and easier accessibility of rural areas to health services. Anacetrapib Stang and Yaen mentioned that the family physician’s example ability to provide a long term relationship with patients can improve the quality of outcomes and their satisfaction of PHC in spite of decreased use of resources.11 However, our study shows that the family physician plan increased the costs and the rate of resources and cannot completely satisfy people and increase the quality desirably because of the inappropriate referral system. Our study showed that the family physician plan has improved the health system. The number of people participating in educational meetings, consultations for family planning, and pop smear tests has increased significantly.