Challenges of implementing outsourcing of primary health services from the perspective of stakeholders.

Abstract

In recent years, outsourcing of primary health services has emerged as a strategic response to growing demands for efficiency and sustainability in healthcare systems. However, especially in low- and middle-income countries like Iran, the implementation of outsourcing faces multiple systemic and contextual challenges. This study aimed to examine the challenges associated with outsourcing primary healthcare services from the perspectives of key stakeholders in Iran. A qualitative study was conducted using directed content analysis, guided by Donabedian's Quality of Care Model and the WHO Health System Governance Framework. Twenty-one stakeholders-including policymakers, university managers, healthcare providers, and private contractors-were selected through purposive and snowball sampling. Semi-structured interviews were conducted, and data were analyzed using MAXQDA 12 software with thematic coding until saturation was reached. A total of 1,150 initial codes were extracted and grouped into 18 subthemes under four main categories: (1) Structural and policy-related challenges (e.g., lack of strong legislation, fragmented governance, contract opacity); (2) Economic challenges (e.g., low profitability, short-term contracts, economic instability); (3) Human resource challenges (e.g., job insecurity, insufficient motivation, workforce instability); and (4) Quality and service outcome challenges (e.g., declining service quality, deviation from outsourcing goals). These findings underscore the multidimensional and interdependent barriers to effective outsourcing. Outsourcing primary health services in Iran is hindered by a combination of legal, financial, managerial, and human resource-related challenges. To ensure effectiveness, policymakers must adopt comprehensive reforms, including national outsourcing legislation, long-term financial frameworks, transparent contract models, and performance-based management systems. Strengthening these foundational elements is critical for promoting sustainability, service quality, and private sector engagement in primary healthcare.