Perceived barriers of telehealth implementation in primary health care in Iran: A qualitative study

Health care begins long before a patient enters a hospital. It starts in the neighborhood, where family doctors and community health workers manage everything from childhood vaccinations to the daily care of chronic conditions like diabetes and high blood pressure. This layer of the system, known as primary health care, is the foundation of a healthy society. For decades, countries like Iran have built extensive networks of local clinics and health posts to ensure that care reaches people in cities, villages, and remote areas. However, these systems face constant pressure. Populations are growing, chronic diseases are becoming more common, and the distance between patients and specialists can be vast. In recent years, the idea of using technology to bridge these gaps has gained momentum. Telehealth, which allows doctors and patients to connect through video calls, phone chats, and digital messages, promises to make care more continuous and accessible. It suggests a future where a patient in a rural village can consult a specialist in a city without traveling for hours.

Yet, simply installing a camera in a clinic does not guarantee success. Technology does not exist in a vacuum; it must fit into a complex web of laws, budgets, human habits, and organizational routines. When a country attempts to introduce telehealth, it is not just buying software; it is trying to change how an entire health system operates. If the internet is unstable, if doctors are not trained, if the rules about who pays for a virtual visit are unclear, or if patients do not trust the system, the technology will sit idle. The challenge is not merely technical; it is deeply human and structural. Understanding why these digital tools succeed or fail requires looking beyond the screen to the people and policies that surround them.

In a recent study, researchers set out to understand exactly what stands in the way of making telehealth work in Iran's primary health care system. They did not look at this from the perspective of a patient sitting at home, but rather from the viewpoint of the people who build, manage, and run the health system. The team, based at Tehran University of Medical Sciences, interviewed sixteen key figures. These included policymakers who write the rules, hospital and clinic managers who organize daily work, doctors who provide care, and technology experts who maintain the systems. The researchers wanted to know what these insiders saw as the biggest hurdles. They listened carefully to their stories, looking for patterns in the problems they described, and organized these findings using a framework that helps researchers understand how new ideas are adopted in complex organizations.

What emerged from these conversations was a picture of a system where the barriers are not isolated problems but a tangled knot of interconnected challenges. The researchers found that the most obvious issue, the lack of reliable technology, was only the tip of the iceberg. While the internet in some rural areas is unstable and power outages can cut off communication, the deeper problems lie in how the system is organized. The study revealed that there is no single authority in charge of telehealth. Different parts of the government and different universities are working on their own projects without talking to each other. This leads to a situation where one clinic might use one type of software and a nearby hospital uses another, and these systems cannot share information. A patient's medical record might be scattered across five different digital platforms that do not connect, forcing doctors to start from scratch every time they see a patient.

Beyond the technical disconnects, the study highlighted a lack of clear rules and financial support. Doctors and clinic managers expressed confusion about who is responsible if something goes wrong during a virtual visit. Is the doctor liable, or is the clinic, or the software provider? Without clear laws defining these responsibilities, many professionals are hesitant to participate. Similarly, the financial side is murky. There are no standard prices for virtual consultations, and insurance companies have not yet figured out how to pay for them. This creates a situation where a doctor might lose money by seeing a patient online compared to seeing them in person, especially since remote visits often do not include the revenue from lab tests or prescriptions that come with in-person appointments. When the people providing the care are not financially supported or legally protected, the system cannot move forward.

The human element also plays a critical role. The researchers found that many doctors and health workers are resistant to changing their traditional ways of working. This is not necessarily because they dislike technology, but because they are accustomed to face-to-face interactions and fear that remote care might compromise the quality of their diagnosis. They worry about the increased workload without extra time or staff to help. Furthermore, there is a cultural dimension to consider. Many patients in Iran prefer to see a doctor in person, to look them in the eye and feel the reassurance of a physical presence. Some groups, particularly older adults or those in remote areas, may not have the digital skills or the devices needed to use these services. If the system assumes everyone has a smartphone and high-speed internet, it risks leaving the most vulnerable people behind.

Perhaps the most significant finding of the study is that these problems cannot be solved one by one. The researchers observed that a failure in one area causes a collapse in another. For example, if the government does not create a clear strategy for how telehealth fits into the broader health system, then clinics will not invest in the necessary equipment. If clinics do not invest, doctors will not be trained, and patients will not trust the service. The study suggests that the path forward requires a coordinated effort that addresses technology, laws, money, and culture all at the same time. It is not enough to build a better internet connection; the system must also have a clear plan for who runs it, how it is paid for, and how it protects patient privacy.

The researchers concluded that for telehealth to become a permanent and useful part of primary health care in Iran, it must be integrated into the existing system rather than added as an afterthought. This means creating a unified strategy where technology supports the flow of care from the local clinic to the specialist, rather than creating a separate, disconnected digital world. It requires clear laws that protect doctors and patients, financial models that make sense for everyone involved, and a cultural shift that builds trust in digital tools. The study does not suggest that telehealth is impossible, but it makes it clear that the path to success is complex. It demands that leaders look at the whole picture, understanding that the technology is just one piece of a much larger puzzle. Until the governance, the rules, the money, and the people are aligned, the potential of telehealth to improve health care will remain largely untapped.