Challenges of Implementing Outsourcing of Primary Health Services from The Perspective of Stakeholders

Challenges of Implementing Outsourcing of Primary Health Services from The Perspective of Stakeholders | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Challenges of Implementing Outsourcing of Primary Health Services from The Perspective of Stakeholders Hosein Ebrahimipour, mehdi yousefi, Saeed tabatabaee, Elahe hoshmand, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4620073/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The primary function of health systems is to provide high-quality and universal health services. Outsourcing, synonymous with contracting-out, has been common in many market-oriented health care reforms. But Lack of attention to the obstacles and challenges of outsourcing health services such as economic issues, responsibility and accountability, human resources challenges, structural problems and private companies, efficiency and planning challenges may lead to failure and irreparable damage to the health system. The present study aimed at identifying the challenges of Outsourcing Health Services to the Private Sector. Method This is a qualitative study that was conducted with the approach of Directed content analysis in 2023. The sampling method was purposeful and sampling continued until data saturation. Data analysis was done using Colaizzi’s method and MAXQAD software. Results After extracting the data, 3 main classes including Challenges of the contractor, Challenges of the employer (university), Manpower challenges and 14 subclasses were extracted. Conclusion The outcomes of this study revealed that outsourcing is one of the basic needs to advance organizational goals. Nonetheless, its current implementation method is not very appropriate. Challenges identified as obstacles to the proper implementation of the partnership plan with the private sector in the field of health are sometimes an integral part of such plans. These challenges must be resolved before the implementation of the plan and during planning by conducting studies and reviewing the project background. This will help to prevent further problems during the execution. Primary Health Care Outsourcing Health Services Private Sector Background The primary function of health systems is to provide high-quality and universal health services. At the same time, through their spending and investments, health systems play an important role in the status and stability of national and regional economies. Health systems play an increasingly important role in driving inclusive and sustainable development through responsible practices in the areas of employment and the purchasing of goods and services.( 1 ) In recent years, with the significant increase in health expenses, most governments have faced many challenges in providing these expenses. For this reason, most governments have included the reform of the health structure, improvement and development of health systems as one of their main priorities.( 2 ) Problems such as inefficiency, lack of accountability and disruption in organizational decisions have made specialists and experts in this field think of reconsidering Organization of the health system and paying attention again to the role of the private sector in providing services alongside the public health sector.( 3 ) Introducing market mechanisms is a common reform of recent years in many European countries ( 4 – 7 ) most notably in Britain, Sweden and the Netherlands.( 6 ) The exact shape of such reforms varies between countries and is influenced by social, economic, cultural and historical issues. Common themes are organizational restructuring, the use of market-type mechanisms, and a focus on performance.( 8 ) It is argued that competing firms produce services at lesser costs and with a more appropriate mix of services.( 9 ) Outsourcing, synonymous with contracting-out, has been common in many market-oriented health care reforms.( 10 , 11 ) The term was coined in business and management in the early 1990s.( 11 ) Outsourcing means transferring services or functions that are traditionally performed in-house to an external provider and controlling through contract and/or partnership management.( 12 ) There is no consensus about the optimal mix of in-house and outsourced functions or services in health care.( 13 ) Outsourcing is increasingly viewed as a policy tool with the potential to increase the access, equity, quality, and efficiency of health care.( 14 ) The practice of outsourcing in industrialized countries began outside the health sector but contracted provision is now a well-established model for delivering health services.( 15 ) For example, in England the National Health Services has long purchased some operations from the private sector ( 16 ), and in the United States many types of organizations manage contracts with providers or contract with competing commercial managed care companies to provide behavioral health services.( 17 ) Outsourcing of health services spread to developing countries in the mid-1990s.( 14 ) The effects of outsourcing issue in health sector can be divided into two categories: short-term and long-term effects. Short-term category comprises cost reduction, changes in the organizational structure, improvement of its quality and access to new technologies and techniques of treatment. Second category effects relate to increase in economic efficiency, organizational development, improvement of quality of services and the medical entity’s image.( 18 ) In Iran, many activities have been carried out in the healthcare sector during the past years with the participation of the private sector. These services include billing, human resources and marketing. Other services that are provided with the participation of the private sector and usually in many hospitals and health centers with the participation of the private sector in the form of outsourcing contracts, include clinical, paraclinical services and providing primary health care. The participation of the private sector in short-term treatment under the direct supervision of tuberculosis is one of the most important examples of providing health services.( 19 ) In the international literature, two major concerns have been raised with respect to outsourcing in public health care. Firstly, even though outsourcing may have many potential benefits in terms of cost reduction( 12 , 20 – 27 ) evidence shows that the actual benefits of outsourcing in health care in terms of cost reduction are often lower than expected. ( 12 , 22 , 24 , 25 , 27 ) Secondly, it has been stated that outsourcing may jeopardize the control over the outsourced functions ( 12 , 25 , 28 ) and, with specific reference to clinical services, it may undermine the public health-care provider’s core competencies.( 12 ) Failure to pay attention to the obstacles and challenges of outsourcing health services such as economic issues, responsibility and accountability, manpower challenges, structural problems and private companies, efficiency and planning challenges may lead to the failure of the project and cause irreparable damage to the body of the health system.( 29 ) Sarabi et al. (2021) in their research entitled "Economic Consequences of Outsourcing Experiences in Public Hospitals in Iran" came to the conclusion that outsourcing in many departments and services of public hospitals has had many successes from an economic point of view, but in some cases, outsourcing has increased costs. Therefore, a wider study in order to identify the influencing factors and negative consequences of outsourcing and strategies to deal with it should be given the attention of hospital managers and health policy makers.( 30 ). The findings of the study by Saeedpour et al. It increases the quality of service, the satisfaction of stakeholders, reduces costs, generates income, etc., using the views of trade union managers who have a long service history is effective in implementing successful decisions.( 31 ) Khan et al. (2022) in Pakistan in their study titled "Identifying Challenges and Practices in Complex Outsourcing Relationships: A Literature Review" concluded that IT outsourcing offers several benefits including cost reduction, greater scalability, and flexibility in the face of is in demand However, due to its complexity, outsourcing usually requires interaction between different stakeholders from different regions and cultures, making it significantly more challenging to manage than traditional outsourcing.( 32 ) Schwarz et al. (2022) in their study titled "Outsourcing nursing staff costs in psychiatry" concluded that outsourcing nursing costs and psychiatric services is a successful factor in reducing costs, especially the cost of caring for patients at home.( 33 ) According to the mentioned materials, it seems that identifying the challenges and obstacles in the implementation of health service outsourcing plans to the private sector is one of the main prerequisites in the field of improving and improving these plans. Therefore, explaining the experiences of managers, employees, and contractor companies in this field will help a lot to identify the challenges of this field. Considering that limited studies have been conducted in this field in the country, this study was conducted to explain the challenges of outsourcing health system services in the field of health. The results of this research provide useful information to policymakers and university health managers to conclude better contracts and provide optimal services. On the other hand, because the government has been looking for outsourcing in the last few years to be able to provide some services by the private sector and also the government is following the policy of privatization of services, therefore many services in different fields including Health has been entrusted to the private sector. Considering that outsourcing is one of the main priorities of government organizations and healthcare centers, therefore, the need to evaluate the strengths weaknesses, and challenges of this field is felt. Considering the importance of the subject, the present study was conducted with the aim of the experiences of managers, employees, and contractor companies in the health field of the University of Medical Sciences regarding the challenges of outsourcing health services. Method The present study is a qualitative study using the method of Directed qualitative study, which examined the challenges of outsourcing health services to the private sector from the perspective of managers, employees, and contractor companies of the Universities of Medical Sciences in 2023. The participants include experts in the field of outsourcing to the private sector at the headquarters of the Universities of Medical Sciences, health assistants of the University of Medical Sciences, university network expansion managers, managers of outsourced health centers, experts of outsourced health centers, experts The financial affairs of the university, the experts of university contracts and the representatives of the contracting company were the parties to the contract in outsourcing. Considering that the researcher's goal in conducting a qualitative study is to reach the meanings and concepts of reality and not its generalizability, and considering that different studies emphasize the maximum diversity of participants in the research in order to achieve the best conceptualization. Therefore, in this study, the purposeful sampling method was used, which is looking for informed people. Also, with the aim of identifying relevant people, the snowball method was also used. According to what was stated, the reason for choosing this sampling method in the qualitative phase of the current study is that targeted sampling by obtaining diverse information makes the nature and dimensions of the phenomenon better investigated. In each of the interviewed levels, the termination of sampling was based on the data saturation pattern, and accordingly, 21 people were interviewed at this stage. The entry criteria in this study are to have an effective background in the subject under study, that is, at least three years of experience in decision-making and planning of health centers, as well as familiarity with outsourcing activities and being an expert in this field. And was interested in participating in the interview. The research environment at this stage was the headquarters of the Universities of Medical Sciences and outsourced health centers. Before conducting the interview, the purpose of the study and the nature of the research were discussed with the people. After assuring the interviewees about the confidentiality of the information and obtaining informed consent from them to record the conversations, questions were asked. In this study, semi-structured interviews were conducted individually or in group discussions. For data analysis, the method of directed or directed content analysis, which is sometimes called analogy-based content analysis, was used. The use of this approach becomes necessary when there are various theories and viewpoints around the research topic, and the purpose of the research is to test previous theories or expand them in a different field. Existing theories and literature in a field can help predict variables and relationships between them. Hence, it is possible to guide the study process in a more structured way by using these previous views. For data analysis, the recorded interviews were first transcribed verbatim. The data were analyzed using the method described by Colaizzi’s method in the following steps. First, the descriptions of the study participants were read to gain an overall understanding. Then the important statements/phrases were extracted. Meanings of important statements/phrases were formulated. The compiled meanings were organized into themes. A detailed description was written for each theme. The basic structure of the phenomenon was formulated and specified in the form of main themes. For this purpose, MAXQAD 12 software was used. Finally, by returning to the interviewees and receiving their opinions, the findings were validated. Results In this study, the participants included 21 employees and experts in the field of outsourcing in the health sector, including 11 women and 10 men, and the age range of the participants was between 23 and 52 years. Table No. 1 is a summary of the demographic information of the interview participants.) Table 1. Demographic information of interview participants Demographic information Number (percentage) Demographic information Number Gender Female 10 ( 48 %) Organizational positions Manager of network development and health promotion 1 Health network manager 1 Health Deputy 1 Male 11 ( 52 %) Director of Family and School Health Department 1 Group manager of the prevention and fight against diseases 1 Age average Female 41.23 Financial manager of the university 1 Head of Oral Health Unit 1 Male 48.67 Head of Environmental and Professional Health Department 1 Head of Education Unit 1 Education level Bachelor's degree 12 ( 57 %) Health care workers 4 Midwife 3 Master's degree 6 ( 29 %) Environmental health and occupational health expert 2 Family physician 1 P.H.D 3 ( 14 %) Representative of the contractor company 1 Contract matters 1 1150 raw codes were obtained from interview analysis and code extraction. Then, by combining these codes, 14 sub-themes or sub-themes and finally 3 main themes or themes were extracted. (Table No. 2), which included outsourcing challenges in three groups: contractor challenges, employer or university challenges, and workforce challenges. Table 2. The main and sub-themes of health sector outsourcing challenges Challenges of the contractor Lack of decision-making authority and financial independence Low profitability Short-term contracts - feeling temporary Absence of a strong protective law Unfair valuation of services Economic instability in the country Challenges of the employer (university) Lack of competitive environment Inefficient performance monitoring and evaluation system Inability to attract groups of doctors and dentists Lack of transparency of contracts Instability of forces Decreasing the quality of service Moving away from the goal of outsourcing Customization of outsourcing Manpower challenges Lack of job security Insufficient motivational mechanisms Feeling of inequality and being ignored Lack of unity of command 1 Challenges of the contractor Contractors and representatives of private companies in outsourcing faced many challenges in this field, which are summarized below. 1-1 Lack of decision-making authority and financial independence One of the biggest and most important challenges of the contractor's side in outsourcing was the lack of decision-making authority and financial independence, which has caused the form of handovers not to proceed according to the principles of outsourcing. In this regard, some participants stated: Participant number 7: " Outsourcing has been done, but in practice, we did not proceed according to the main principles of outsourcing. The first principle in outsourcing is to give financial independence to the private sector, that is, in exchange for the money we give you, we want you to manage a special center for us. We want this quality from you, we will pay this much, and you don't have to deal with the details anymore . " Participant number 13: " When the company does not have the right to make decisions and practical independence in any field, it cannot have management ." 1-2 Low profitability The next challenge for the contractors was to make little profit, due to the low price of the outsourcing contracts and also the existing strict laws, the remaining amount of the contract, which is meant as a profit for the companies, is very small compared to the challenges and problems related to outsourcing. This motivation has reduced the presence of the private sector in outsourcing. Participant No. 15: " The money that is paid to the companies as an outsourcing contract, with these strict rules on the payment of personnel salaries, practically does not have anything else for the company except a very little management right ." Participant number 18" It has a small profit that is not worth the trouble at all, which is why no company or private sector wants to enter this field. The health sector is not very attractive for the private sector because of its nature, it is necessary to provide free services to the people and you cannot earn money in this way ." 1-3 Short-term contracts - feeling temporary According to the laws of the Ministry of Health and the National Inspection Organization, outsourcing contracts must be concluded for one year, so that at the end of each year, by holding a tender, companies that have the ability to perform work at a lower price can be given the opportunity to participate in the tender. But the short term of the contracts has caused the contractor to feel temporary and see the time horizon of its progress as short term. In this regard, some interviewees stated: Participant 7 : " A series of items should be amended. For example, the requirement that all contracts must be signed for one year. This is a law that is not known for what purpose it was signed and what was the background of this law. Good. Obviously, no private company with any vision is willing to sign a one-year contract. As a private company, I put in the best performance and best energy to perform well, if a company comes next year and gives a lower price and wins the tender, what is my duty? I have to be unemployed ." 1-4 Absence of a strong protective law Because outsourcing does not have a strong protection law at the level of the legislature and the parliament, and often the laws related to outsourcing are proposed and approved at the level of the university's board of trustees, and in the implementation, the contractor company may not be able to rely on it when faced with problems. To be supported by these laws. Participant No. 17: " If each university implements its own law, we will not be able to reach a single law for outsourcing in the country. When a single law is not implemented in the country, legislators at high levels do not care to consider this issue as a package." It should be considered complete, that is, for example, I want to implement a handover model in Torbet University. This handover model that I am doing, the ultimate goal is that I can approve it within the authority of the university's board of trustees. Here, I can no longer go to the parliament or the ministry. I mean, when you enact a law that is at the level of your university's board of trustees, on the other hand, the upper laws of the country may not be in line with your laws, you come up with a series of them based on what you have in mind. You take it and adapt it to the rules of the upper level. It is the same famous example that the cook who is divided into two, the food is either salty or unsalted. Like the family doctor who went to the level of the parliament, maybe we need to reach a certain form in the Ministry of Health in this handover model and go to pass as a law in the parliament some items that can be the upstream law of these contracts. Overshadow it, let's amend it right there, for example, say that this law has been handed over, so the private sector is no longer applicable here, for example, accountable supervision is not applicable here, in this way, many interferences will be removed ." 1-5 Unfair valuation of services During the implementation of service purchase and performance-based payment plans, one of the most important issues that should be addressed is service valuation, through which we can move towards a proper outsourcing by clarifying the service and its value. In this regard, the participants stated that currently the valuation is unfair Participant No. 12: " In the beginning, when the volume and definition of the health sector services were done, this volume was correct, but what was wrong in the middle was the valuation of the services. The valuation of the services was based on savings. It was a manpower. Look, if we see everything in reality that is implemented everywhere and is not comparable, it is great. The working hours are per day. The performance-based payment system means that if you want to get the salary equal to 8 hours per day, you must also do the secretary's work in addition to being the secretary of the boss. 1-6 Economic instability in the country One of the problems of private companies in outsourcing is the lack of economic stability and inflation in the country, and with the rapid increase in prices, it is very difficult to conclude a contract with the amount that was determined a year ago. Participant No. 3: "When a company comes and wins the tender and starts working, it is the first problem, because with this economic situation, prices change every day, but the company receives the same money as written in the contract in the first year. Many times, companies They face problems in supplying their equipment and consumables, which means that at the end of the year, with these prices, the company has not made a profit and has nothing left." 2- Employer Challenges The employer or the university has also faced many challenges and problems in outsourcing, some of which are mentioned below. 2-1 Lack of competitive environment: One of the major problems of universities during outsourcing is the lack of presence and acceptance of the private sector in this field, and practically the number of companies applying for outsourcing is very few. This has caused outsourcing companies to move towards monopoly instead of a competitive environment. Participant No. 1: " Due to the problems of outsourcing, applicants are very limited in outsourcing tenders, not having the right to choose has caused the competitive environment to disappear and on the one hand, instead of competition, we move towards monopoly. We are in a type 3 university, in this way, when we bid for outsourcing, we don't have many applicants because according to our budget, it is not enough for the companies to work, that's why the companies are limited, and we don't have many applicants, and therefore the power We have no choice ." 2-2 Inefficient performance monitoring and evaluation system Another problem that the university faces in handovers is the lack of a monitoring and accurate performance evaluation system. Due to the lack of a strong test verification system, it is not possible to accurately measure the performance of the special department in this field. Participant No. 9: " Performance evaluation is: the process of evaluating the success or failure of employees' performance based on predetermined performance evaluation indicators.When there are no strong indicators in this field, it is not possible to comment on success or failure. " Participant No. 6: " In previous courses, it has been observed that when the only indicator for monitoring the performance of personnel is the number of services, regardless of their quality, people only go towards filling out paper forms, and the quality and Actual performance is ignored ." 2-3 Inability to attract groups of doctors and dentists In addition to the problems that exist in the weak presence of the private sector applying for outsourcing, the provision of specialized personnel, especially the group of doctors and dentists, in less privileged and remote areas due to the low attractiveness of providing services in the health sector, has caused the university to face many challenges. Participant No. 3: " The amount stated in the instruction ( executive instruction for the provision and promotion of primary health care in urban and rural areas ) and we have to sign a contract according to it is very small, so doctors do not welcome them to come for this reason. We have a lot of problems to provide doctors in these areas, the doctors who come with these working conditions and salaries are not stable and they leave soon . " 2-4 Lack of transparency in contracts Transparency in the contract means considering all possible aspects that may arise during the execution of a contract and providing a clear solution regarding these matters, but the participants in the interview stated that there are many blind spots in the current contracts that cause It does not have the necessary transparency. Participant No. 5: " Not all cases have been seen in the contracts, and this makes the companies not responsible in some issues that are not clear, for example, the labor department fined the company according to the labor law, but they put the responsibility on the university . Because the companies and their representatives and even those who wrote the contract in the university, sometimes they do not have the complete authority to perform those services and they have not had executive work, they do not include a series of issues in the contracts, this causes many problems later, because the first thought We haven't done it, now when we deal with the problem, we get confused, but if the professional forces who have done the field work are present during the contracts, the contracts will be more transparent and many of these problems will not occur anymore . " 2-5 Instability of forces One of the important challenges that has arisen for the university due to the short term of the contracts is the lack of stability of the workforce, which changes with the change of the company's subordinate forces. The participants in the interview also confirmed this and expressed they had: Participant No. 7: " Because the forces are corporate and constantly changing, the lack of stability of the forces makes it impossible to find the real patients. For example, an expert in combating patients must know his service area well, know the people of that area and to be able to communicate with them in order to make a basic diagnosis . " Participant number 12: " The university spends money, conducts tests, recruits, trains, spends and delivers the company, and when the contract of the company ends, these forces remain undecided. New forces come again and this process is repeated again . " 2-6 Decreasing the quality of service Decreasing the quality of services was also one of the challenges that the interviewees expressed as the adverse effects of the current outsourcing system Participant No. 4: " Company forces that have a temporary status are not motivated to work, and sometimes they are only satisfied with the completion of programs and move more towards paperwork than they want to have real performance ." Participant No. 21: " When the basis of payment is only the number of services, without any monitoring of the quality and quantity of these services, as a result, employees to do only the number of tasks requested so that their salaries are not reduced. They are moving towards creating fake data and recording unreal documents ." 2-7 Moving away from the main purpose of outsourcing The involvement of the university in outsourcing challenges and affairs has caused outsourcing to move away from its main path and main goal Participant No. 19: " We are so worried about cost, recruitment and tendering that we forget that the purpose of outsourcing is to improve the quality and efficiency and reduce the size of the government. If we consider these goals, our work will go much better. It may take more time and patience, but in the end, we will get a good result, but unfortunately, in the discussion of outsourcing that is being done now, it seems that the main goal of outsourcing has been completely forgotten . " 2-8 Customization of outsourcing The lack of precise, clear and unified rules in the field of outsourcing and assigning this matter to each university has caused outsourcing and contracting in each university to be done according to taste and there is no fixed procedure in all universities. Participant No. 2: " If we are going to present a general model for handing over health care centers to the private sector, it is better to work on a general and basic model and be consistent for all universities. A basic model should be designed and then notified to the entire universities. Not that contract should be left to any university that makes contracts according to its own taste ." Participant No. 10: " When there is no clear instruction to outsource services, our managers act arbitrarily and outsource services that could be managed with the organization's forces without preliminary study and investigation. And instead, they don't outsource some activities that private companies can do much better ." 3- workforce challenges The workforce as one of the important elements in outsourcing also faced important challenges such as lack of job security, lack of sufficient motivational mechanisms, feeling of inequality and lack of unity of command. 3-1 Lack of job security The perception of job security is conceptualized as the perception of security from maintaining and not losing a job, which is one of the cases and examples of the feeling of security, which forms the strongest motivational level of a person after physiological needs.(34) This need in the work environment is It is fulfilled by ensuring the continuity of work.(35) In fact, the perception of job security is a state that is the result of a person's evaluation of personal, organizational and environmental conditions and leads him to the conclusion that a certain factor does not threaten his job security. And he can be sure of the continuation of his employment now and in the future. If organizations cannot apply job security in new concepts, they cannot achieve the necessary efficiency and effectiveness from the proper job performance of their employees. Because the lack of job security hinders the empowerment of employees in terms of specialization, practical courage, learning experience, job satisfaction, work conscience and promotion opportunities, as a result, the professional and social expectations of organizations are not met.(36) In this regard, some participants stated: Participant No. 4: " The short duration of university outsourcing contracts, which are mostly one year, and on the other hand, the difficult conditions and the contract renewal process with contractors have caused most contractors to work in an environment where both they and their personnel do not feel job security. We don't know how long to write a contract with our employee and we are losing most of our expert staff because of this ." Participant number 12: " Every day we have to be stressed that the conditions of the decisions may change or a new company may come and they don't want us anymore ." Participant No. 17: " At the end of the year, we have to stress so that they don't renew the contract this year." 3-2 Insufficient motivational mechanisms Motivation is an internal driving force that determines the intensity, direction and continuity of a person's effort towards the realization of a goal (37) , in other words, motivation is an internal state that causes energy generation, determining the direction and intensity of a behavior to reach a goal.(38) Correct management in the organization creates that managers strive by recognizing and anticipating the motivations of the human resources under their management so that they can satisfy their needs correctly and in time to improve their activity and real efficiency in To provide for organizational goals (39) In this regard, the employees considered the motivational situation insufficient and stated: Participant No.6: " The forces are completely unmotivated. The company oppresses them a lot. Of course, these are educated forces, they know their rights better, but the law does not help them much. They usually compare themselves with other forces when they are so They see discrimination and difference, they become unmotivated and it affects their work . Participant No. 18: " For me, who is employed by the government, my salary is different according to my years of service. There are a number of things such as class and group that increase with years and affect my salary, but these benefits exist for contract personnel. And this issue can greatly affect their morale and motivation. In my opinion, the problem of motivating company employees is very serious due to the lack of job security and lack of these benefits . " 3-3 Feeling of inequality and being overlooked According to Adams' "equality" theory, job satisfaction is the result of the behavior that is done towards us compared to others. Members and employees of the organization do not work in a vacuum. They always compare themselves with "others".(40) The basis of comparison (other) may be a member of the same work group, or another person in other departments of the organization, or even a group of people outside the organization. After evaluating how the organization deals with "person" and "other", the results of the evaluations are compared with each other and the person compares his position with another position. The result of this comparison for a person may be a feeling of equality or inequality. Adams describes the process of comparing equality in terms of input and output ratios. Data means what the individual gives to the organization, such as education, experience, effort, and loyalty. Staff also received the person from the organization in return, such as salary, reputation, social relations and internal rewards. One part of the evaluation of the data and data is based on objective observations (for example, the rights of the individual) and the other part is based on the perception of the individual. The following relationship represents equality comparison. A person compares his data-to-data ratio with another data-to-data ratio. In the theory of equality, it is said that employees and members of the organization, if they feel unfair towards themselves, may reduce the level of their activity or distort or disrupt the level of consumption of themselves and others (as well as efficiency). They behave in such a way that others are encouraged to work less, reduce their consumption (data) and productivity, change the reference or what the person compares himself with, or leave the organization.(41) This issue was raised as one of the challenges of the workforce and in this regard the participants had the title Participant No. 12: " Official employees of the same rank and our colleagues have less workload and more income than us, We do the same work in the same room, we have the same degree, but because we are a corporate force and they are official, our salaries and benefits differ from earth to heaven .” Participant number 4: " When working, they tell us that you are also an employee of the same system and you have to work for the system, but when it comes to bonuses and other benefits, it's as if we don't exist at all, they don't see us at all ." 3-4 Lack of unity of command: Unity of Command, which is sometimes referred to as the chain of command, is one of the 14 principles of artistic management by Fayol, and it means that each employee must receive orders from a superior to do any work.(42) The participants in the interview stated in this regard. Participant number 12: "" Corporate forces are recruited and selected by the university and work in the company. On the one hand, since the force is a company, it must be accountable to the contractor and pursue the goals of its superiors. On the other hand, it must also be accountable to the university. The employee has several bosses and receives orders from several bosses, and sometimes the orders of these bosses overlap . Participant No. 17: " We have 100 superiors, each of them gives an order and we have to execute it. All this is written in management books about unity of command, but the exact opposite of this is happening here. We have to answer to several people as leaders ." Discussion and Conclusion The data of this qualitative study included a list of challenges of outsourced comprehensive health centers in Iran's health system, which are divided into three groups: the challenges of the contractor, the challenges of the employer or the university itself (including: lack of competitive environment, inefficient monitoring system And the evaluation of performance was the inability to attract a group of doctors and dentists, the lack of transparency of contracts, the instability of forces, the reduction of service quality, moving away from the goal of outsourcing, the customization of outsourcing) and the challenges of the workforce. Outsourcing in the field of healthcare is different from other sectors due to the special nature of these services, and considering the financial profit and loss of outsourcing can cause irreparable damage to the health of society. Also, paying attention to the challenges in the process of outsourcing services to the private sector and planning to solve them can be an effective step in increasing the effectiveness of outsourcing projects. In a study conducted in developing countries, the obstacles to outsourcing the healthcare sector to the private sector include the lack of specific items that can be outsourced, the lack of trust between the outsourcer and the executive, the lack of information control resources, and the lack of necessary laws( 10 ), which is consistent with the results. The present study is consistent. In Rasi et al.'s study entitled "Challenges of outsourcing health services to the private sector from the perspective of Mashhad University of Medical Sciences employees", seven main challenges were included: economic issues, structural problems, manpower challenges, responsibility and accountability, program challenges. It was smallness, efficiency and private companies.( 29 ) Although this study has investigated the challenges of the treatment sector and hospitals in outsourcing, but the results of this study are consistent with the current study under the topics of structural problems and human resources challenges. Has it. The challenge of manpower was one of the most important issues raised by the participants and the analysis of the participants' point of view, the challenges raised in this dimension included lack of job security, insufficient motivational mechanisms, feeling of inequality and being ignored, lack of unity of command. The findings of Saharkhiz et al.'s study entitled "Survey of Obstacles to Privatization in Nursing" show that the highest scores in the field of obstacles to privatization of nurses are related to nurses' concern about job security, the lack of a comprehensive set of rules for the development of the private sector in nursing, and significant discrimination.( 43 ) Although this study has specifically addressed the challenges of nursing staff in outsourcing, but from the point of view of the challenges of outsourcing, from the perspective of private sector employees or corporate forces with some challenges raised. It is consistent with the interviewees of this study who mentioned the challenges from the perspective of private sector employees. Also, in Hatami et al.'s study entitled "Explaining the experiences of managers, employees and contractor companies in the health field of Zahedan University of Medical Sciences regarding the challenges of outsourcing health services", the challenges raised in the labor force aspect include discrimination in payments, threats from the private sector and dissatisfaction with the service. Were recipients. Regarding the discrimination in payments, the experiences of the participants confirmed that with the implementation of this plan and increasing the gap between the income of official forces and corporate forces, the motivation of employees has been affected by this discrimination and injustice,( 44 ) which is consistent with the results of the present study. The noteworthy point is to consider the social, cultural and economic conditions and the state of the health service delivery system in the country. Mere imitation of privatization projects in other countries without considering the local conditions of the country can lead to the failure of these plans. According to the presented materials, it seems that the challenges identified as obstacles to the optimal implementation of the partnership plan with the private sector in the field of health are sometimes an integral part of such plans, which can be done before the implementation of the plan and during the program. Rezi prevented future problems during implementation by conducting studies and reviewing the plan in advance with special attention to them. Declarations Ethical approval: The procedures followed in the present study caused no physical or psychological harm to the subjects. At the beginning of the interview, the purpose of the study, and data confidentiality were explained to the participants and written and verbal consent were obtained for face to face and telephone interviews, respectively. The subjects had the right to withdraw from the study at any time. The study has been approved by Ethics Committee of Mashhad University of medical Sciences (code: IR.MUMS.FHMPM.REC.1401.019). Consent for publication Not applicable. Availability of data and materials The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Competing interests The authors have no conflicts of interest to declare. Funding This research is an excerpt from a research project approved with code 4000510 at Mashhad University of Medical Sciences, which was sponsored by this university Authors' contributions SJ: Conception and design, Acquisition of data, Analysis and interpretation of data, drafting of the manuscript, Statistical analysis . HE: Conception and design, Critical revision of the manuscript for important intellectual content, Obtaining funding, Administrative, technical, or material support, Supervision . MY: Critical revision of the manuscript for important intellectual content, Statistical analysis, Obtaining funding, technical, or material support, Supervision. ST: Analysis and interpretation of data, Critical revision of the manuscript for important intellectual content, Administrative. EH: Drafting of the manuscript, Obtaining funding. AT: Analysis and interpretation of data, Statistical analysis. Acknowledgements This study is a part of the Ph.D. thesis on healthcare services management in 2024 with the code of ethics IR.MUMS.FHMPM.REC.1401.019 at Mashhad University of Medical Sciences. The authors of this study are grateful to the Research Vice-Chancellor of the University of Medical Sciences for their financial and spiritual support of this project and to all the people who collaborated in this research. References Boyce T, Brown C. Economic and social impacts and benefits of health systems. Economic and social impacts and benefits of health systems. 2019. Kavosi Z, Rahimi H, Khanian S, Farhadi P, Kharazmi E. Factors influencing decision making for healthcare services outsourcing: A review and Delphi study. Med J Islamic Repub Iran. 2018;32:56. Mokrini AE, Aouam T. A fuzzy multi-criteria decision analysis approach for risk evaluation in healthcare logistics outsourcing: Case of Morocco. Health Serv Manage Res. 2020;33(3):143–55. Van de Ven WP. Market-oriented health care reforms: trends and future options. Soc Sci Med. 1996;43(5):655–66. Vining AR, Globerman S. Contracting-out health care services: a conceptual framework. Health Policy. 1999;46(2):77–96. Harrison MI, Calltorp J. The reorientation of market-oriented reforms in Swedish health-care. Health Policy. 2000;50(3):219–40. Robinson R, Jakubowski E, Figueras J. Organization of purchasing in Europe. Purchasing to improve health systems performance. 2005:11–43. Haque MS. Revisiting the new public management. Heinonline; 2007. Kavanagh S. Purchasers, providers and managed care: developments in the mental health market place. Curr Opin Psychiatry. 1997;10(2):153–9. Siddiqi S, Masud TI, Sabri B. Contracting but not without caution: experience with outsourcing of health services in countries of the Eastern Mediterranean Region. Bull World Health Organ. 2006;84:867–75. Kenner C, Pressler JL. When does outsourcing become a right source for academic excellence? Nurse Educ. 2006;31(4):139–41. Roberts V. Managing strategic outsourcing in the healthcare industry. J Healthc Manag. 2001;46(4):239. Hazelwood SE, Hazelwood AC, Cook ED. Possibilities and pitfalls of outsourcing. Healthc Financial Manage. 2005;59(10):44–9. Liu X, Hotchkiss D, Bose S, Bitran R. Contracting out for primary health services: evidence of its effects and a framework for evaluation. Phrplus Project unded by USAID; 2004. Loevinsohn B, Harding A. Buying results? Contracting for health service delivery in developing countries. Lancet. 2005;366(9486):676–81. Timmins N. Challenges of private provision in the NHS. BMJ. 2005;331(7526):1193–5. Rosenthal MB, Minden S, Manderscheid R, Henderson M. A typology of organizational and contractual arrangements for purchasing and delivery of behavioral health care. Adm Policy Mental Health Mental Health Serv Res. 2006;33:461–9. Czerw A, Kowalska M, Religioni U. Public health Differences in the use of outsourcing in public and private institutions providing medical services. Archives Med Sci. 2014;10(3):618–29. Farahbakhsh M, Nikniaz A, Tabrizi J, Jahanbin H, Abdolahi H, Zakeri A, et al. Comparison of government and cooperative health centers with regard to services and health cares. J School Public Health Inst Public Health Res. 2007;5(2):1–11. Wholey DR, Christianson JB, Peterson M. Organizing the delivery of mental health services: contracting for metal health care by health maintenance organizations. Admin Policy Mental Health. 1996;23:307–28. Wholey DR, Padman R, Hamer R, Schwartz S. Determinants of information technology outsourcing among health maintenance organizations. Health Care Manag Sci. 2001;4:229–39. Willcocks LR, Currie WL. Contracting out information technology in public sector contexts: research and critique. J Manage Organ. 1997;3(2):34–49. Shinkman R. Outsourcing on the Upswing. Mod Healthc. 2000;30(37):46–50. Young S. Outsourcing and downsizing: processes of workplace change in public health. economic labour relations Rev. 2002;13(2):244–69. Billi JE, Pai C-W, Spahlinger DA. Strategic outsourcing of clinical services: a model for volume-stressed academic medical centers. Health Care Manage Rev. 2004;29(4):291–7. Hartley K, Huby M. Contracting-out in health and local authorities: Prospects, progress and pitfalls. Public Money Manage. 1985;5(2):23–6. Domberger S, Rimmer S. Competitive tendering and contracting in the public sector: A survey. Int J Econ Business. 1994;1(3):439–53. JANSSENS SM MOHAGHEGHS. Outsourcing Versus in-House Provision of Sleep Diagnostic Services. Cambridge: JAABC; 2005. pp. 336–42. Rasi. doosty f, reihani yasavoli a. The Challenges of Outsourcing Health Services to the Private Sector from the Viewpoint of Employees of Mashhad University of Medical Sciences: A Qualitative Study. Social Secur J. 2018;14(3):117–34. Sarabi-Asiabar A, Azami-Aghdash S, Rezapour A, Kalajahi RA, Taghizadeh S, Amuzadeh S et al. Economic Consequences of Outsourcing in Public Hospitals in Iran: A Systematic Review. J Health Adm. 2021;24(1). Saeidpour J, Faridfar N, Ghaziasgar M. Factors affecting the implementation of outsourcing in Tehran university of medical sciences hospitals: Hospital administrators’ vision. Payavard Salamat. 2019;13(2):142–50. Khan GM, Khan SU, Khan HU, Ilyas M. Challenges and practices identification in complex outsourcing relationships: A systematic literature review. PLoS ONE. 2022;17(1):e0262710. Schwarz J, Heinze M, Holzke M, Klär A, Löhr M, Schaffert R et al. Outsourcing of nursing staff costs in psychiatry? A secondary data analysis of possible effects on the remuneration system in psychiatry. Nervenarzt. 2022:1–7. Mosadeghrad A, Sokhanvar M. Organizational culture of selected hospitals of Tehran city. 2017. Hajizadeh Maymandi M, Bonyad L. Factors affecting occupational safety employee organizations (meta-analysis of available research). Q J Social Dev (Previously Hum Development). 2020;14(2):33–60. Vahidi Zadeh A, Barzegar M, Ahmadi E. The role of mediation of job security in the relationship between organizational identity and staff empowering. J New Approaches Educational Adm. 2017;8(30):85–104. Judge TA, Robbins SP. Essentials of organizational behavior. Pearson Education (us); 2017. De Lourdes Machado-Taylor M, Meira Soares V, Brites R, Brites Ferreira J, Farhangmehr M, Gouveia OMR, et al. Academic job satisfaction and motivation: Findings from a nationwide study in Portuguese higher education. Stud High Educ. 2016;41(3):541–59. Koklan H. Tehran Organizational Behavior, University of Tehran, School of Management and Business Sciences. Robbins E. Organizational behavior, concepts, theories, applications. Translation: A., Parsaian and Other, Tehran: Cultural Research Office; 19991377. Rifin M. Organizational behavior. Translation: Seyyed Mohammad Alwani and another. Tehran: Marwarid; 1996. S.M A. Public Management.. Tehran: Ney Publishing; 2012. Saharkhiz H, Anoosheh M. Assessing the obstacles of outsourcing in nursing. Q J Nurs Manage. 2016;4(4):28–36. Hatami A, Khammarnia M, Zanganeh Baygi M, Peyvand M. Explaining Experiences of Managers. Employees, and. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4620073","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":318821689,"identity":"607140c1-9802-4530-bb5f-32c5c69b2a9b","order_by":0,"name":"Hosein Ebrahimipour","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hosein","middleName":"","lastName":"Ebrahimipour","suffix":""},{"id":318821690,"identity":"81d20b56-2e70-4fbd-8b3e-56bcf5760d13","order_by":1,"name":"mehdi yousefi","email":"","orcid":"","institution":"The University of Warwick","correspondingAuthor":false,"prefix":"","firstName":"mehdi","middleName":"","lastName":"yousefi","suffix":""},{"id":318821691,"identity":"742053da-43d8-43d3-b520-58684b7806cb","order_by":2,"name":"Saeed tabatabaee","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Saeed","middleName":"","lastName":"tabatabaee","suffix":""},{"id":318821692,"identity":"9c2fdd77-54ed-48f3-a301-95be0bd5cd34","order_by":3,"name":"Elahe hoshmand","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Elahe","middleName":"","lastName":"hoshmand","suffix":""},{"id":318821693,"identity":"aef2cf9a-11e7-4514-9ae4-208a85cf4636","order_by":4,"name":"Ali taghipour","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"taghipour","suffix":""},{"id":318821694,"identity":"5ab5584b-80c3-4a92-99d8-c1d466ddc19d","order_by":5,"name":"sara jamili","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIiWNgGAWjYNACHgYGNnbGxgcMDAdI0cLM2GxAghYQYGZgkyBKi3z72YcfGGTsovmYmduqeWruyPEzMD98dAOPFoMz6cYSDDzJuW3MjG23eY49M5ZsYDM2zsGnhSGNAaiFGaqF7XDihgM8bNL4tMj3P2P+wcBTD9ZSzPOPCC0MN9KAvuY5DNbCzNtGhBaDG8/YLBJ4joO0NEvO7TtsLNlMwC/y/WnMNz72VOfOb29/+OHNt8Ny/OzNDx/jdRgIJPZAaCYeEMlMSDkY/IBQjD+IUj0KRsEoGAUjDQAA+JtFiJ75V8kAAAAASUVORK5CYII=","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"sara","middleName":"","lastName":"jamili","suffix":""}],"badges":[],"createdAt":"2024-06-22 05:06:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4620073/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4620073/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":65053325,"identity":"ba090f91-4f0f-4ee8-b9ce-0abcb68e6714","added_by":"auto","created_at":"2024-09-23 06:29:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":532137,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4620073/v1/1b79c366-05d2-45b4-90ae-fa77a1ff13cf.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Challenges of Implementing Outsourcing of Primary Health Services from The Perspective of Stakeholders","fulltext":[{"header":"Background","content":" \u003cp\u003eThe primary function of health systems is to provide high-quality and universal health services. At the same time, through their spending and investments, health systems play an important role in the status and stability of national and regional economies. Health systems play an increasingly important role in driving inclusive and sustainable development through responsible practices in the areas of employment and the purchasing of goods and services.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn recent years, with the significant increase in health expenses, most governments have faced many challenges in providing these expenses. For this reason, most governments have included the reform of the health structure, improvement and development of health systems as one of their main priorities.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Problems such as inefficiency, lack of accountability and disruption in organizational decisions have made specialists and experts in this field think of reconsidering Organization of the health system and paying attention again to the role of the private sector in providing services alongside the public health sector.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIntroducing market mechanisms is a common reform of recent years in many European countries (\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) most notably in Britain, Sweden and the Netherlands.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) The exact shape of such reforms varies between countries and is influenced by social, economic, cultural and historical issues. Common themes are organizational restructuring, the use of market-type mechanisms, and a focus on performance.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) It is argued that competing firms produce services at lesser costs and with a more appropriate mix of services.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOutsourcing, synonymous with contracting-out, has been common in many market-oriented health care reforms.(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) The term was coined in business and management in the early 1990s.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) Outsourcing means transferring services or functions that are traditionally performed in-house to an external provider and controlling through contract and/or partnership management.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) There is no consensus about the optimal mix of in-house and outsourced functions or services in health care.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOutsourcing is increasingly viewed as a policy tool with the potential to increase the access, equity, quality, and efficiency of health care.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) The practice of outsourcing in industrialized countries began outside the health sector but contracted provision is now a well-established model for delivering health services.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) For example, in England the National Health Services has long purchased some operations from the private sector (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), and in the United States many types of organizations manage contracts with providers or contract with competing commercial managed care companies to provide behavioral health services.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) Outsourcing of health services spread to developing countries in the mid-1990s.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe effects of outsourcing issue in health sector can be divided into two categories: short-term and long-term effects. Short-term category comprises cost reduction, changes in the organizational structure, improvement of its quality and access to new technologies and techniques of treatment. Second category effects relate to increase in economic efficiency, organizational development, improvement of quality of services and the medical entity\u0026rsquo;s image.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn Iran, many activities have been carried out in the healthcare sector during the past years with the participation of the private sector. These services include billing, human resources and marketing. Other services that are provided with the participation of the private sector and usually in many hospitals and health centers with the participation of the private sector in the form of outsourcing contracts, include clinical, paraclinical services and providing primary health care. The participation of the private sector in short-term treatment under the direct supervision of tuberculosis is one of the most important examples of providing health services.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn the international literature, two major concerns have been raised with respect to outsourcing in public health care. Firstly, even though outsourcing may have many potential benefits in terms of cost reduction(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21 CR22 CR23 CR24 CR25 CR26\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) evidence shows that the actual benefits of outsourcing in health care in terms of cost reduction are often lower than expected. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) Secondly, it has been stated that outsourcing may jeopardize the control over the outsourced functions (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) and, with specific reference to clinical services, it may undermine the public health-care provider\u0026rsquo;s core competencies.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eFailure to pay attention to the obstacles and challenges of outsourcing health services such as economic issues, responsibility and accountability, manpower challenges, structural problems and private companies, efficiency and planning challenges may lead to the failure of the project and cause irreparable damage to the body of the health system.(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) Sarabi et al. (2021) in their research entitled \"Economic Consequences of Outsourcing Experiences in Public Hospitals in Iran\" came to the conclusion that outsourcing in many departments and services of public hospitals has had many successes from an economic point of view, but in some cases, outsourcing has increased costs. Therefore, a wider study in order to identify the influencing factors and negative consequences of outsourcing and strategies to deal with it should be given the attention of hospital managers and health policy makers.(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). The findings of the study by Saeedpour et al. It increases the quality of service, the satisfaction of stakeholders, reduces costs, generates income, etc., using the views of trade union managers who have a long service history is effective in implementing successful decisions.(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) Khan et al. (2022) in Pakistan in their study titled \"Identifying Challenges and Practices in Complex Outsourcing Relationships: A Literature Review\" concluded that IT outsourcing offers several benefits including cost reduction, greater scalability, and flexibility in the face of is in demand However, due to its complexity, outsourcing usually requires interaction between different stakeholders from different regions and cultures, making it significantly more challenging to manage than traditional outsourcing.(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSchwarz et al. (2022) in their study titled \"Outsourcing nursing staff costs in psychiatry\" concluded that outsourcing nursing costs and psychiatric services is a successful factor in reducing costs, especially the cost of caring for patients at home.(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) According to the mentioned materials, it seems that identifying the challenges and obstacles in the implementation of health service outsourcing plans to the private sector is one of the main prerequisites in the field of improving and improving these plans. Therefore, explaining the experiences of managers, employees, and contractor companies in this field will help a lot to identify the challenges of this field. Considering that limited studies have been conducted in this field in the country, this study was conducted to explain the challenges of outsourcing health system services in the field of health. The results of this research provide useful information to policymakers and university health managers to conclude better contracts and provide optimal services. On the other hand, because the government has been looking for outsourcing in the last few years to be able to provide some services by the private sector and also the government is following the policy of privatization of services, therefore many services in different fields including Health has been entrusted to the private sector. Considering that outsourcing is one of the main priorities of government organizations and healthcare centers, therefore, the need to evaluate the strengths weaknesses, and challenges of this field is felt. Considering the importance of the subject, the present study was conducted with the aim of the experiences of managers, employees, and contractor companies in the health field of the University of Medical Sciences regarding the challenges of outsourcing health services.\u003c/p\u003e"},{"header":"Method","content":" \u003cp\u003eThe present study is a qualitative study using the method of Directed qualitative study, which examined the challenges of outsourcing health services to the private sector from the perspective of managers, employees, and contractor companies of the Universities of Medical Sciences in 2023.\u003c/p\u003e \u003cp\u003e The participants include experts in the field of outsourcing to the private sector at the headquarters of the Universities of Medical Sciences, health assistants of the University of Medical Sciences, university network expansion managers, managers of outsourced health centers, experts of outsourced health centers, experts The financial affairs of the university, the experts of university contracts and the representatives of the contracting company were the parties to the contract in outsourcing.\u003c/p\u003e \u003cp\u003eConsidering that the researcher's goal in conducting a qualitative study is to reach the meanings and concepts of reality and not its generalizability, and considering that different studies emphasize the maximum diversity of participants in the research in order to achieve the best conceptualization. Therefore, in this study, the purposeful sampling method was used, which is looking for informed people. Also, with the aim of identifying relevant people, the snowball method was also used.\u003c/p\u003e \u003cp\u003eAccording to what was stated, the reason for choosing this sampling method in the qualitative phase of the current study is that targeted sampling by obtaining diverse information makes the nature and dimensions of the phenomenon better investigated. In each of the interviewed levels, the termination of sampling was based on the data saturation pattern, and accordingly, 21 people were interviewed at this stage.\u003c/p\u003e \u003cp\u003eThe entry criteria in this study are to have an effective background in the subject under study, that is, at least three years of experience in decision-making and planning of health centers, as well as familiarity with outsourcing activities and being an expert in this field. And was interested in participating in the interview. The research environment at this stage was the headquarters of the Universities of Medical Sciences and outsourced health centers.\u003c/p\u003e \u003cp\u003eBefore conducting the interview, the purpose of the study and the nature of the research were discussed with the people. After assuring the interviewees about the confidentiality of the information and obtaining informed consent from them to record the conversations, questions were asked. In this study, semi-structured interviews were conducted individually or in group discussions.\u003c/p\u003e \u003cp\u003eFor data analysis, the method of directed or directed content analysis, which is sometimes called analogy-based content analysis, was used. The use of this approach becomes necessary when there are various theories and viewpoints around the research topic, and the purpose of the research is to test previous theories or expand them in a different field. Existing theories and literature in a field can help predict variables and relationships between them. Hence, it is possible to guide the study process in a more structured way by using these previous views.\u003c/p\u003e \u003cp\u003eFor data analysis, the recorded interviews were first transcribed verbatim. The data were analyzed using the method described by Colaizzi\u0026rsquo;s method in the following steps.\u003c/p\u003e \u003cp\u003eFirst, the descriptions of the study participants were read to gain an overall understanding.\u003c/p\u003e \u003cp\u003eThen the important statements/phrases were extracted.\u003c/p\u003e \u003cp\u003eMeanings of important statements/phrases were formulated.\u003c/p\u003e \u003cp\u003eThe compiled meanings were organized into themes.\u003c/p\u003e \u003cp\u003eA detailed description was written for each theme.\u003c/p\u003e \u003cp\u003eThe basic structure of the phenomenon was formulated and specified in the form of main themes.\u003c/p\u003e \u003cp\u003eFor this purpose, MAXQAD 12 software was used. Finally, by returning to the interviewees and receiving their opinions, the findings were validated.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn this study, the participants included 21 employees and experts in the field of outsourcing in the health sector, including 11 women and 10 men, and the age range of the participants was between 23 and 52 years. Table No. 1 is a summary of the demographic information of the interview participants.)\u003c/p\u003e\n\u003cp\u003eTable 1. Demographic information of interview participants\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"630\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.524642289348172%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eDemographic information\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.400635930047695%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eNumber (percentage)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.62798092209857%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eDemographic information\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.446740858505564%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eNumber\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.559618441971383%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eGender\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.8060413354531%\" rowspan=\"3\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eFemale\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.400635930047695%\" rowspan=\"3\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e10\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; (\u003c/strong\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e48\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.241653418124006%\" rowspan=\"15\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eOrganizational positions\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.54531001589825%\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eManager of network development and health promotion\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.446740858505564%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e1\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"74.5583038869258%\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eHealth network manager\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.441696113074205%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e1\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"74.5583038869258%\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp; Health Deputy\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.441696113074205%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e1\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.67864693446089%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eMale\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49048625792812%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e11\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp; (\u003c/strong\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e52\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.60887949260042%\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eDirector of Family and\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;School Health Department\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.221987315010571%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e1\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"74.5583038869258%\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eGroup manager of the prevention\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eand fight against diseases\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.441696113074205%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e1\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.31159420289855%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eAge\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eaverage\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28985507246377%\" rowspan=\"2\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eFemale\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.130434782608695%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e41.23\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.22463768115942%\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eFinancial manager\u003c/span\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;of the university\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e1\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"74.5583038869258%\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eHead of Oral Health Unit\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.441696113074205%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e1\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.67864693446089%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eMale\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49048625792812%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e48.67\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.60887949260042%\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eHead of Environmental and Professional Health Department\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.221987315010571%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e1\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"74.5583038869258%\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eHead of Education Unit\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.441696113074205%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e1\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.31159420289855%\" rowspan=\"6\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eEducation\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;level\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28985507246377%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eBachelor\u0026apos;s\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;degree\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.130434782608695%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e12\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; (\u003c/strong\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e57\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.22463768115942%\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eHealth care workers\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.043478260869565%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e4\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"74.5583038869258%\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eMidwife\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.441696113074205%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e3\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.67864693446089%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eMaster\u0026apos;s degree\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49048625792812%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e6\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp; (\u003c/strong\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e29\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.60887949260042%\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eEnvironmental health and\u003c/span\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;occupational health expert\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.221987315010571%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e2\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"74.5583038869258%\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eFamily physician\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.441696113074205%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e1\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.67864693446089%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eP.H.D\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49048625792812%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e3\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp; (\u003c/strong\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e14\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.60887949260042%\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eRepresentative of the contractor company\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.221987315010571%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e1\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"74.5583038869258%\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eContract matters\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.441696113074205%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e1\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e1150 raw codes were obtained from interview analysis and code extraction. Then, by combining these codes, 14 sub-themes or sub-themes and finally 3 main themes or themes were extracted. (Table No. 2), which included outsourcing challenges in three groups: contractor challenges, employer or university challenges, and workforce challenges.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2. The main and sub-themes of health sector outsourcing challenges\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.63402889245586%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eChallenges of the contractor\u003c/span\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.36597110754414%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eLack of decision-making authority and financial independence\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eLow profitability\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eShort-term contracts - feeling temporary\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eAbsence of a strong protective law\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eUnfair valuation of services\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eEconomic instability in the country\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.63402889245586%\" rowspan=\"8\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;Challenges of the employer (university)\u003c/span\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.36597110754414%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eLack of competitive environment\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eInefficient performance monitoring and evaluation system\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eInability to attract groups of doctors and dentists\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eLack of transparency of contracts\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eInstability of forces\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eDecreasing the quality of service\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eMoving away from the goal of outsourcing\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eCustomization of outsourcing\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.63402889245586%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;Manpower challenges\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.36597110754414%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eLack of job security\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eInsufficient motivational mechanisms\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eFeeling of inequality and being ignored\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eLack of unity of command\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e1 \u0026nbsp; \u0026nbsp;Challenges of the contractor\u003c/p\u003e\n\u003cp\u003eContractors and representatives of private companies in outsourcing faced many challenges in this field, which are summarized below.\u003c/p\u003e\n\u003cp\u003e1-1\u0026nbsp;Lack of decision-making authority and financial independence\u003c/p\u003e\n\u003cp\u003eOne of the biggest and most important challenges of the contractor\u0026apos;s side in outsourcing was the lack of decision-making authority and financial independence, which has caused the form of handovers not to proceed according to the principles of outsourcing. In this regard, some participants stated:\u003c/p\u003e\n\u003cp\u003eParticipant number 7: \u0026quot;\u003cem\u003eOutsourcing has been done, but in practice, we did not proceed according to the main principles of outsourcing. The first principle in outsourcing is to give financial independence to the private sector, that is, in exchange for the money we give you, we want you to manage a special center for us. We want this quality from you, we will pay this much, and you don\u0026apos;t have to deal with the details anymore\u003c/em\u003e.\u003cspan dir=\"RTL\"\u003e\u0026quot;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eParticipant number 13: \u0026quot;\u003cem\u003eWhen the company does not have the right to make decisions and practical independence in any field, it cannot have management\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n\u003cp\u003e1-2\u0026nbsp;Low profitability\u003c/p\u003e\n\u003cp\u003eThe next challenge for the contractors was to make little profit, due to the low price of the outsourcing contracts and also the existing strict laws, the remaining amount of the contract, which is meant as a profit for the companies, is very small compared to the challenges and problems related to outsourcing. This motivation has reduced the presence of the private sector in outsourcing.\u003c/p\u003e\n\u003cp\u003eParticipant No. 15: \u0026quot;\u003cem\u003eThe money that is paid to the companies as an outsourcing contract, with these strict rules on the payment of personnel salaries, practically does not have anything else for the company except a very little management right\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n\u003cp\u003eParticipant number 18\u0026quot; \u003cem\u003eIt has a small profit that is not worth the trouble at all, which is why no company or private sector wants to enter this field.\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eThe health sector is not very attractive for the private sector because of its nature, it is necessary to provide free services to the people and you cannot earn money in this way\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n\u003cp\u003e1-3 \u0026nbsp; Short-term contracts - feeling temporary\u003c/p\u003e\n\u003cp\u003eAccording to the laws of the Ministry of Health and the National Inspection Organization, outsourcing contracts must be concluded for one year, so that at the end of each year, by holding a tender, companies that have the ability to perform work at a lower price can be given the opportunity to participate in the tender. But the short term of the contracts has caused the contractor to feel temporary and see the time horizon of its progress as short term. In this regard, some interviewees stated:\u003c/p\u003e\n\u003cp\u003eParticipant \u003cspan dir=\"RTL\"\u003e7\u003c/span\u003e: \u0026quot;\u003cem\u003eA series of items should be amended. For example, the requirement that all contracts must be signed for one year. This is a law that is not known for what purpose it was signed and what was the background of this law. Good. Obviously, no private company with any vision is willing to sign a one-year contract. As a private company, I put in the best performance and best energy to perform well, if a company comes next year and gives a lower price and wins the tender, what is my duty? I have to be unemployed\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n\u003cp\u003e1-4 Absence of a strong protective law\u003c/p\u003e\n\u003cp\u003eBecause outsourcing does not have a strong protection law at the level of the legislature and the parliament, and often the laws related to outsourcing are proposed and approved at the level of the university\u0026apos;s board of trustees, and in the implementation, the contractor company may not be able to rely on it when faced with problems. To be supported by these laws.\u003c/p\u003e\n\u003cp\u003eParticipant No. 17: \u0026quot;\u003cem\u003eIf each university implements its own law, we will not be able to reach a single law for outsourcing in the country. When a single law is not implemented in the country, legislators at high levels do not care to consider this issue as a package.\u0026quot; It should be considered complete, that is, for example, I want to implement a handover model in Torbet University. This handover model that I am doing, the ultimate goal is that I can approve it within the authority of the university\u0026apos;s board of trustees. Here, I can no longer go to the parliament or the ministry. I mean, when you enact a law that is at the level of your university\u0026apos;s board of trustees, on the other hand, the upper laws of the country may not be in line with your laws, you come up with a series of them based on what you have in mind. You take it and adapt it to the rules of the upper level. It is the same famous example that the cook who is divided into two, the food is either salty or unsalted. Like the family doctor who went to the level of the parliament, maybe we need to reach a certain form in the Ministry of Health in this handover model and go to pass as a law in the parliament some items that can be the upstream law of these contracts. Overshadow it, let\u0026apos;s amend it right there, for example, say that this law has been handed over, so the private sector is no longer applicable here, for example, accountable supervision is not applicable here, in this way, many interferences will be removed\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n\u003cp\u003e1-5 Unfair valuation of services\u003c/p\u003e\n\u003cp\u003eDuring the implementation of service purchase and performance-based payment plans, one of the most important issues that should be addressed is service valuation, through which we can move towards a proper outsourcing by clarifying the service and its value. In this regard, the participants stated that currently the valuation is unfair\u003c/p\u003e\n\u003cp\u003eParticipant No. 12: \u0026quot;\u003cem\u003eIn the beginning, when the volume and definition of the health sector services were done, this volume was correct, but what was wrong in the middle was the valuation of the services. The valuation of the services was based on savings. It was a manpower. Look, if we see everything in reality that is implemented everywhere and is not comparable, it is great. The working hours are per day. The performance-based payment system means that if you want to get the salary equal to 8 hours per day, you must also do the secretary\u0026apos;s work in addition to being the secretary of the boss.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e1-6 Economic instability in the country\u003c/p\u003e\n\u003cp\u003eOne of the problems of private companies in outsourcing is the lack of economic stability and inflation in the country, and with the rapid increase in prices, it is very difficult to conclude a contract with the amount that was determined a year ago.\u003c/p\u003e\n\u003cp\u003eParticipant No. 3: \u0026quot;When a company comes and wins the tender and starts working, it is the first problem, because with this economic situation, prices change every day, but the company receives the same money as written in the contract in the first year. Many times, companies They face problems in supplying their equipment and consumables, which means that at the end of the year, with these prices, the company has not made a profit and has nothing left.\u0026quot;\u003c/p\u003e\n\u003cp\u003e2- Employer Challenges\u003c/p\u003e\n\u003cp\u003eThe employer or the university has also faced many challenges and problems in outsourcing, some of which are mentioned below.\u003c/p\u003e\n\u003cp\u003e2-1 Lack of competitive environment:\u003c/p\u003e\n\u003cp\u003eOne of the major problems of universities during outsourcing is the lack of presence and acceptance of the private sector in this field, and practically the number of companies applying for outsourcing is very few.\u003c/p\u003e\n\u003cp\u003eThis has caused outsourcing companies to move towards monopoly instead of a competitive environment.\u003c/p\u003e\n\u003cp\u003eParticipant No. 1: \u0026quot;\u003cem\u003eDue to the problems of outsourcing, applicants are very limited in outsourcing tenders, not having the right to choose has caused the competitive environment to disappear and on the one hand, instead of competition, we move towards monopoly.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe are in a type 3 university, in this way, when we bid for outsourcing, we don\u0026apos;t have many applicants because according to our budget, it is not enough for the companies to work, that\u0026apos;s why the companies are limited, and we don\u0026apos;t have many applicants, and therefore the power We have no choice\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n\u003cp\u003e2-2 Inefficient performance monitoring and evaluation system\u003c/p\u003e\n\u003cp\u003eAnother problem that the university faces in handovers is the lack of a monitoring and accurate performance evaluation system. Due to the lack of a strong test verification system, it is not possible to accurately measure the performance of the special department in this field.\u003c/p\u003e\n\u003cp\u003eParticipant No. 9: \u0026quot; \u003cem\u003ePerformance evaluation is: the process of evaluating the success or failure of employees\u0026apos; performance based on predetermined performance evaluation indicators.When there are no strong indicators in this field, it is not possible to comment on success or failure.\u003c/em\u003e \u0026quot;\u003c/p\u003e\n\u003cp\u003eParticipant No. 6: \u0026quot;\u003cem\u003eIn previous courses, it has been observed that when the only indicator for monitoring the performance of personnel is the number of services, regardless of their quality, people only go towards filling out paper forms, and the quality and Actual performance is ignored\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n\u003cp\u003e2-3 Inability to attract groups of doctors and dentists\u003c/p\u003e\n\u003cp\u003eIn addition to the problems that exist in the weak presence of the private sector applying for outsourcing, the provision of specialized personnel, especially the group of doctors and dentists, in less privileged and remote areas due to the low attractiveness of providing services in the health sector, has caused the university to face many challenges.\u003c/p\u003e\n\u003cp\u003eParticipant No. 3: \u0026quot;\u003cem\u003eThe amount stated in the instruction (\u003c/em\u003eexecutive instruction for the provision and promotion of primary health care in urban and rural areas\u003cem\u003e) and we have to sign a contract according to it is very small, so doctors do not welcome them to come for this reason. We have a lot of problems to provide doctors in these areas, the doctors who come with these working conditions and salaries are not stable and they leave soon\u003c/em\u003e.\u003cspan dir=\"RTL\"\u003e\u0026quot;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e2-4 Lack of transparency in contracts\u003c/p\u003e\n\u003cp\u003eTransparency in the contract means considering all possible aspects that may arise during the execution of a contract and providing a clear solution regarding these matters, but the participants in the interview stated that there are many blind spots in the current contracts that cause It does not have the necessary transparency.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Participant No. 5: \u0026quot;\u003cem\u003eNot all cases have been seen in the contracts, and this makes the companies not responsible in some issues that are not clear, for example, the labor department fined the company according to the labor law, but they put the responsibility on the university\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBecause the companies and their representatives and even those who wrote the contract in the university, sometimes they do not have the complete authority to perform those services and they have not had executive work, they do not include a series of issues in the contracts, this causes many problems later, because the first thought We haven\u0026apos;t done it, now when we deal with the problem, we get confused, but if the professional forces who have done the field work are present during the contracts, the contracts will be more transparent and many of these problems will not occur anymore\u003c/em\u003e.\u003cspan dir=\"RTL\"\u003e\u0026quot;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e2-5 Instability of forces\u003c/p\u003e\n\u003cp\u003eOne of the important challenges that has arisen for the university due to the short term of the contracts is the lack of stability of the workforce, which changes with the change of the company\u0026apos;s subordinate forces. The participants in the interview also confirmed this and expressed they had:\u003c/p\u003e\n\u003cp\u003eParticipant No. 7: \u0026quot;\u003cem\u003eBecause the forces are corporate and constantly changing, the lack of stability of the forces makes it impossible to find the real patients. For example, an expert in combating patients must know his service area well, know the people of that area and to be able to communicate with them in order to make a basic diagnosis\u003c/em\u003e.\u003cspan dir=\"RTL\"\u003e\u0026quot;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eParticipant number 12: \u0026quot;\u003cem\u003eThe university spends money, conducts tests, recruits, trains, spends and delivers the company, and when the contract of the company ends, these forces remain undecided. New forces come again and this process is repeated again\u003c/em\u003e. \u0026quot;\u003c/p\u003e\n\u003cp\u003e2-6 Decreasing the quality of service\u003c/p\u003e\n\u003cp\u003eDecreasing the quality of services was also one of the challenges that the interviewees expressed as the adverse effects of the current outsourcing system\u003c/p\u003e\n\u003cp\u003eParticipant No. 4: \u0026quot;\u003cem\u003eCompany forces that have a temporary status are not motivated to work, and sometimes they are only satisfied with the completion of programs and move more towards paperwork than they want to have real performance\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n\u003cp\u003eParticipant No. 21: \u0026quot;\u003cem\u003eWhen the basis of payment is only the number of services, without any monitoring of the quality and quantity of these services, as a result, employees to do only the number of tasks requested so that their salaries are not reduced.\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eThey are moving towards creating fake data and recording unreal documents\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n\u003cp\u003e2-7 Moving away from the main purpose of outsourcing\u003c/p\u003e\n\u003cp\u003eThe involvement of the university in outsourcing challenges and affairs has caused outsourcing to move away from its main path and main goal\u003c/p\u003e\n\u003cp\u003eParticipant No. 19: \u0026quot;\u003cem\u003eWe are so worried about cost, recruitment and tendering that we forget that the purpose of outsourcing is to improve the quality and efficiency and reduce the size of the government. If we consider these goals, our work will go much better. It may take more time and patience, but in the end, we will get a good result, but unfortunately, in the discussion of outsourcing that is being done now, it seems that the main goal of outsourcing has been completely forgotten\u003c/em\u003e.\u003cspan dir=\"RTL\"\u003e\u0026quot;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e2-8 Customization of outsourcing\u003c/p\u003e\n\u003cp\u003eThe lack of precise, clear and unified rules in the field of outsourcing and assigning this matter to each university has caused outsourcing and contracting in each university to be done according to taste and there is no fixed procedure in all universities.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Participant No. 2: \u0026quot;\u003cem\u003eIf we are going to present a general model for handing over health care centers to the private sector, it is better to work on a general and basic model and be consistent for all universities. A basic model should be designed and then notified to the entire universities. Not that contract should be left to any university that makes contracts according to its own taste\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n\u003cp\u003eParticipant No. 10: \u0026quot;\u003cem\u003eWhen there is no clear instruction to outsource services, our managers act arbitrarily and outsource services that could be managed with the organization\u0026apos;s forces without preliminary study and investigation.\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eAnd instead, they don\u0026apos;t outsource some activities that private companies can do much better\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n\u003cp\u003e3- workforce challenges\u003c/p\u003e\n\u003cp\u003eThe workforce as one of the important elements in outsourcing also faced important challenges such as lack of job security, lack of sufficient motivational mechanisms, feeling of inequality and lack of unity of command.\u003c/p\u003e\n\u003cp\u003e3-1 Lack of job security\u003c/p\u003e\n\u003cp\u003eThe perception of job security is conceptualized as the perception of security from maintaining and not losing a job, which is one of the cases and examples of the feeling of security, which forms the strongest motivational level of a person after physiological needs.(34) This need in the work environment is It is fulfilled by ensuring the continuity of work.(35) In fact, the perception of job security is a state that is the result of a person\u0026apos;s evaluation of personal, organizational and environmental conditions and leads him to the conclusion that a certain factor does not threaten his job security. And he can be sure of the continuation of his employment now and in the future. If organizations cannot apply job security in new concepts, they cannot achieve the necessary efficiency and effectiveness from the proper job performance of their employees. Because the lack of job security hinders the empowerment of employees in terms of specialization, practical courage, learning experience, job satisfaction, work conscience and promotion opportunities, as a result, the professional and social expectations of organizations are not met.(36) In this regard, some participants stated:\u003c/p\u003e\n\u003cp\u003eParticipant No. 4: \u0026quot;\u003cem\u003eThe short duration of university outsourcing contracts, which are mostly one year, and on the other hand, the difficult conditions and the contract renewal process with contractors have caused most contractors to work in an environment where both they and their personnel do not feel job security. We don\u0026apos;t know how long to write a contract with our employee and we are losing most of our expert staff because of this\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n\u003cp\u003eParticipant number 12: \u0026quot;\u003cem\u003eEvery day we have to be stressed that the conditions of the decisions may change or a new company may come and they don\u0026apos;t want us anymore\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n\u003cp\u003eParticipant No. 17: \u0026quot;\u003cem\u003eAt the end of the year, we have to stress so that they don\u0026apos;t renew the contract this year.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e3-2 Insufficient motivational mechanisms\u003c/p\u003e\n\u003cp\u003eMotivation is an internal driving force that determines the intensity, direction and continuity of a person\u0026apos;s effort towards the realization of a goal\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003cspan dir=\"RTL\"\u003e(37)\u003c/span\u003e, in other words, motivation is an internal state that causes energy generation, determining the direction and intensity of a behavior to reach a goal.(38)\u0026nbsp;Correct management in the organization creates that managers strive by recognizing and anticipating the motivations of the human resources under their management so that they can satisfy their needs correctly and in time to improve their activity and real efficiency in To provide for organizational goals\u0026nbsp;(39)\u0026nbsp;In this regard, the employees considered the motivational situation insufficient and stated:\u003c/p\u003e\n\u003cp\u003eParticipant No.6: \u0026quot;\u003cem\u003eThe forces are completely unmotivated. The company oppresses them a lot. Of course, these are educated forces, they know their rights better, but the law does not help them much. They usually compare themselves with other forces when they are so They see discrimination and difference, they become unmotivated and it affects their work\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eParticipant No. 18: \u0026quot; \u003cem\u003eFor me, who is employed by the government, my salary is different according to my years of service. There are a number of things such as class and group that increase with years and affect my salary, but these benefits exist for contract personnel. And this issue can greatly affect their morale and motivation. In my opinion, the problem of motivating company employees is very serious due to the lack of job security and lack of these benefits\u003c/em\u003e.\u003cspan dir=\"RTL\"\u003e\u0026quot;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e3-3 Feeling of inequality and being overlooked\u003c/p\u003e\n\u003cp\u003eAccording to Adams\u0026apos; \u0026quot;equality\u0026quot; theory, job satisfaction is the result of the behavior that is done towards us compared to others. Members and employees of the organization do not work in a vacuum. They always compare themselves with \u0026quot;others\u0026quot;.(40)\u0026nbsp;The basis of comparison (other) may be a member of the same work group, or another person in other departments of the organization, or even a group of people outside the organization. After evaluating how the organization deals with \u0026quot;person\u0026quot; and \u0026quot;other\u0026quot;, the results of the evaluations are compared with each other and the person compares his position with another position. The result of this comparison for a person may be a feeling of equality or inequality. Adams describes the process of comparing equality in terms of input and output ratios. Data means what the individual gives to the organization, such as education, experience, effort, and loyalty. Staff also received the person from the organization in return, such as salary, reputation, social relations and internal rewards. One part of the evaluation of the data and data is based on objective observations (for example, the rights of the individual) and the other part is based on the perception of the individual. The following relationship represents equality comparison.\u003c/p\u003e\n\u003cp\u003eA person compares his data-to-data ratio with another data-to-data ratio. In the theory of equality, it is said that employees and members of the organization, if they feel unfair towards themselves, may reduce the level of their activity or distort or disrupt the level of consumption of themselves and others (as well as efficiency). They behave in such a way that others are encouraged to work less, reduce their consumption (data) and productivity, change the reference or what the person compares himself with, or leave the organization.(41) This issue was raised as one of the challenges of the workforce and in this regard the participants had the title\u003c/p\u003e\n\u003cp\u003eParticipant No. 12: \u0026quot;\u003cem\u003eOfficial employees of the same rank and our colleagues have less workload and more income than us, We do the same work in the same room, we have the same degree, but because we are a corporate force and they are official, our salaries and benefits differ from earth to heaven\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eParticipant number 4: \u0026quot;\u003cem\u003eWhen working, they tell us that you are also an employee of the same system and you have to work for the system, but when it comes to bonuses and other benefits, it\u0026apos;s as if we don\u0026apos;t exist at all, they don\u0026apos;t see us at all\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n\u003cp\u003e3-4 Lack of unity of command:\u003c/p\u003e\n\u003cp\u003eUnity of Command, which is sometimes referred to as the chain of command, is one of the 14 principles of artistic management by Fayol, and it means that each employee must receive orders from a superior to do any work.(42) The participants in the interview stated in this regard.\u003c/p\u003e\n\u003cp\u003eParticipant number 12: \u0026quot;\u0026quot;\u003cem\u003eCorporate forces are recruited and selected by the university and work in the company. On the one hand, since the force is a company, it must be accountable to the contractor and pursue the goals of its superiors. On the other hand, it must also be accountable to the university. The employee has several bosses and receives orders from several bosses, and sometimes the orders of these bosses overlap\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eParticipant No. 17: \u0026quot;\u003cem\u003eWe have 100 superiors, each of them gives an order and we have to execute it. All this is written in management books about unity of command, but the exact opposite of this is happening here. We have to answer to several people as leaders\u003c/em\u003e.\u0026quot;\u003c/p\u003e"},{"header":"Discussion and Conclusion","content":"\u003cp\u003eThe data of this qualitative study included a list of challenges of outsourced comprehensive health centers in Iran's health system, which are divided into three groups: the challenges of the contractor, the challenges of the employer or the university itself (including: lack of competitive environment, inefficient monitoring system And the evaluation of performance was the inability to attract a group of doctors and dentists, the lack of transparency of contracts, the instability of forces, the reduction of service quality, moving away from the goal of outsourcing, the customization of outsourcing) and the challenges of the workforce.\u003c/p\u003e \u003cp\u003eOutsourcing in the field of healthcare is different from other sectors due to the special nature of these services, and considering the financial profit and loss of outsourcing can cause irreparable damage to the health of society. Also, paying attention to the challenges in the process of outsourcing services to the private sector and planning to solve them can be an effective step in increasing the effectiveness of outsourcing projects.\u003c/p\u003e \u003cp\u003eIn a study conducted in developing countries, the obstacles to outsourcing the healthcare sector to the private sector include the lack of specific items that can be outsourced, the lack of trust between the outsourcer and the executive, the lack of information control resources, and the lack of necessary laws(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), which is consistent with the results. The present study is consistent.\u003c/p\u003e \u003cp\u003eIn Rasi et al.'s study entitled \"Challenges of outsourcing health services to the private sector from the perspective of Mashhad University of Medical Sciences employees\", seven main challenges were included: economic issues, structural problems, manpower challenges, responsibility and accountability, program challenges. It was smallness, efficiency and private companies.(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) Although this study has investigated the challenges of the treatment sector and hospitals in outsourcing, but the results of this study are consistent with the current study under the topics of structural problems and human resources challenges. Has it.\u003c/p\u003e \u003cp\u003eThe challenge of manpower was one of the most important issues raised by the participants and the analysis of the participants' point of view, the challenges raised in this dimension included lack of job security, insufficient motivational mechanisms, feeling of inequality and being ignored, lack of unity of command.\u003c/p\u003e \u003cp\u003eThe findings of Saharkhiz et al.'s study entitled \"Survey of Obstacles to Privatization in Nursing\" show that the highest scores in the field of obstacles to privatization of nurses are related to nurses' concern about job security, the lack of a comprehensive set of rules for the development of the private sector in nursing, and significant discrimination.(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) Although this study has specifically addressed the challenges of nursing staff in outsourcing, but from the point of view of the challenges of outsourcing, from the perspective of private sector employees or corporate forces with some challenges raised. It is consistent with the interviewees of this study who mentioned the challenges from the perspective of private sector employees.\u003c/p\u003e \u003cp\u003eAlso, in Hatami et al.'s study entitled \"Explaining the experiences of managers, employees and contractor companies in the health field of Zahedan University of Medical Sciences regarding the challenges of outsourcing health services\", the challenges raised in the labor force aspect include discrimination in payments, threats from the private sector and dissatisfaction with the service. Were recipients. Regarding the discrimination in payments, the experiences of the participants confirmed that with the implementation of this plan and increasing the gap between the income of official forces and corporate forces, the motivation of employees has been affected by this discrimination and injustice,(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) which is consistent with the results of the present study.\u003c/p\u003e \u003cp\u003eThe noteworthy point is to consider the social, cultural and economic conditions and the state of the health service delivery system in the country. Mere imitation of privatization projects in other countries without considering the local conditions of the country can lead to the failure of these plans. According to the presented materials, it seems that the challenges identified as obstacles to the optimal implementation of the partnership plan with the private sector in the field of health are sometimes an integral part of such plans, which can be done before the implementation of the plan and during the program. Rezi prevented future problems during implementation by conducting studies and reviewing the plan in advance with special attention to them.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe procedures followed in the present study caused no physical or psychological harm to the subjects. At the beginning of the interview, the purpose of the study, and data confidentiality were explained to the participants and written and verbal consent were obtained for face to face and telephone interviews, respectively. The subjects had the right to withdraw from the study at any time. The study has been approved by Ethics Committee of Mashhad University of medical Sciences (code: IR.MUMS.FHMPM.REC.1401.019).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research is an excerpt from a research project approved with code 4000510 at Mashhad University of Medical Sciences, which was sponsored by this university\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSJ: Conception and design, Acquisition of data, Analysis and interpretation of data, drafting of the manuscript, Statistical analysis\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e HE: Conception and design, Critical revision of the manuscript for important intellectual content, Obtaining funding, Administrative, technical, or material support, Supervision\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e MY: Critical revision of the manuscript for important intellectual content, Statistical analysis, Obtaining funding, technical, or material support, Supervision. ST: Analysis and interpretation of data, Critical revision of the manuscript for important intellectual content, Administrative. EH: Drafting of the manuscript, Obtaining funding. AT: Analysis and interpretation of data, Statistical analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is a part of the Ph.D. thesis on healthcare services management in 2024 with the code of ethics IR.MUMS.FHMPM.REC.1401.019 at Mashhad University of Medical Sciences. The authors of this study are grateful to the Research Vice-Chancellor of the University of Medical Sciences for their financial and spiritual support of this project and to all the people who collaborated in this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBoyce T, Brown C. Economic and social impacts and benefits of health systems. 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Pearson Education (us); 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Lourdes Machado-Taylor M, Meira Soares V, Brites R, Brites Ferreira J, Farhangmehr M, Gouveia OMR, et al. Academic job satisfaction and motivation: Findings from a nationwide study in Portuguese higher education. Stud High Educ. 2016;41(3):541\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoklan H. Tehran Organizational Behavior, University of Tehran, School of Management and Business Sciences.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobbins E. Organizational behavior, concepts, theories, applications. Translation: A., Parsaian and Other, Tehran: Cultural Research Office; 19991377.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRifin M. Organizational behavior. Translation: Seyyed Mohammad Alwani and another. Tehran: Marwarid; 1996.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eS.M A. Public Management.. 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Employees, and.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Primary Health Care, Outsourcing Health Services, Private Sector","lastPublishedDoi":"10.21203/rs.3.rs-4620073/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4620073/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe primary function of health systems is to provide high-quality and universal health services. Outsourcing, synonymous with contracting-out, has been common in many market-oriented health care reforms. But Lack of attention to the obstacles and challenges of outsourcing health services such as economic issues, responsibility and accountability, human resources challenges, structural problems and private companies, efficiency and planning challenges may lead to failure and irreparable damage to the health system. The present study aimed at identifying the challenges of Outsourcing Health Services to the Private Sector.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThis is a qualitative study that was conducted with the approach of Directed content analysis in 2023. The sampling method was purposeful and sampling continued until data saturation. Data analysis was done using Colaizzi\u0026rsquo;s method and MAXQAD software.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAfter extracting the data, 3 main classes including Challenges of the contractor, Challenges of the employer (university), Manpower challenges and 14 subclasses were extracted.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe outcomes of this study revealed that outsourcing is one of the basic needs to advance organizational goals. Nonetheless, its current implementation method is not very appropriate. Challenges identified as obstacles to the proper implementation of the partnership plan with the private sector in the field of health are sometimes an integral part of such plans. These challenges must be resolved before the implementation of the plan and during planning by conducting studies and reviewing the project background. This will help to prevent further problems during the execution.\u003c/p\u003e","manuscriptTitle":"Challenges of Implementing Outsourcing of Primary Health Services from The Perspective of Stakeholders","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-15 03:45:19","doi":"10.21203/rs.3.rs-4620073/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"507a3f57-5b51-4119-a07f-0e418723db56","owner":[],"postedDate":"July 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-10T04:23:17+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-15 03:45:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4620073","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4620073","identity":"rs-4620073","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}