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

Ebrahimipour et al. BMC Primary Care (2025) 26:355 https://doi.org/10.1186/s12875-025-03045-z BMC Primary Care Open Access RESEARCH Challenges of implementing outsourcing of primary health services from the perspective of stakeholders Hosein Ebrahimipour1,3 , Mehdi Yousefi2 , Saeed Tabatabaee1,3 , Elaheh Hooshmand3 , Ali Taghipour4 Sara Jamili5* and Abstract Background In recent years, outsourcing of primary health services has emerged as a strategic response to growing demands for efficiency and sustainability in healthcare systems. However, especially in low- and middle-income countries like Iran, the implementation of outsourcing faces multiple systemic and contextual challenges. This study aimed to examine the challenges associated with outsourcing primary healthcare services from the perspectives of key stakeholders in Iran. Methods A qualitative study was conducted using directed content analysis, guided by Donabedian’s Quality of Care Model and the WHO Health System Governance Framework. Twenty-one stakeholders—including policymakers, university managers, healthcare providers, and private contractors—were selected through purposive and snowball sampling. Semi-structured interviews were conducted, and data were analyzed using MAXQDA 12 software with thematic coding until saturation was reached. Results A total of 1,150 initial codes were extracted and grouped into 18 subthemes under four main categories: (1) Structural and policy-related challenges (e.g., lack of strong legislation, fragmented governance, contract opacity); (2) Economic challenges (e.g., low profitability, short-term contracts, economic instability); (3) Human resource challenges (e.g., job insecurity, insufficient motivation, workforce instability); and (4) Quality and service outcome challenges (e.g., declining service quality, deviation from outsourcing goals). These findings underscore the multidimensional and interdependent barriers to effective outsourcing. Conclusion Outsourcing primary health services in Iran is hindered by a combination of legal, financial, managerial, and human resource-related challenges. To ensure effectiveness, policymakers must adopt comprehensive reforms, including national outsourcing legislation, long-term financial frameworks, transparent contract models, and performance-based management systems. Strengthening these foundational elements is critical for promoting sustainability, service quality, and private sector engagement in primary healthcare. Keywords Outsourcing, Primary health care, Stakeholders, Iran, Qualitative research *Correspondence: Sara Jamili Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Ebrahimipour et al. BMC Primary Care (2025) 26:355 Background The primary function of health systems is to deliver high-quality, equitable, and universal health services to populations [1]. Moreover, health systems play a crucial role in shaping national and regional economies through investments in infrastructure, employment, and service delivery [2]. In recent years, the rapid growth of healthcare expenditures has presented significant challenges to many governments in maintaining the financial sustainability of health systems [3]. As a response, structural reforms and the incorporation of private sector capacities have been increasingly considered [4]. One of the major policy reforms in public service delivery has been the adoption of public-private partnerships (PPP), which aim to combine the strengths of both sectors to improve efficiency, access, and service quality [5]. These changes are rooted in broader trends in New Public Management (NPM) and Public Administration Reform, which emphasize decentralization, efficiency, and market-based approaches. Underlying these reforms are theoretical models such as Social Exchange Theory [6], which highlights the importance of reciprocal relationships and trust between stakeholders, and Transaction Cost Theory, which explains the efficiency of outsourcing based on cost-benefit analysis of internal versus external service provision [7]. Outsourcing, also referred to as contracting-out, has emerged as a widely used tool within healthcare systems aiming to improve performance, cost-efficiency, and responsiveness. Several studies have suggested that outsourcing can increase access, equity, and service quality [8]. However, the evidence remains mixed. Some studies have highlighted that the expected cost reductions from outsourcing are often less significant than projected and that outsourcing can sometimes compromise service quality and staff satisfaction [9]. In countries like England, the National Health Service (NHS) has long engaged in outsourcing arrangements through PPP models, particularly for elective surgeries (e.g., cataract operations), diagnostic services, and specialized care provided by Independent Sector Treatment Centres [9]. In the United States, outsourcing of behavioral health services and managed care models is common [10]. In the Iranian context, outsourcing of health services has included administrative services (billing, marketing), clinical and paraclinical services, and the provision of primary health care in rural and urban areas. One notable example is the private sector’s involvement in Directly Observed Treatment (DOT) for tuberculosis control [11]. Nevertheless, international literature has identified major concerns regarding outsourcing in public healthcare. First, the actual financial savings are often lower than predicted [12]. Second, the delegation of service Page 2 of 11 provision may weaken governmental control over essential functions, especially in clinical areas where continuity and accountability are critical [9]. Given the complex nature of healthcare services— characterized by human sensitivity, professional ethics, and the importance of public trust—outsourcing in this domain is fundamentally different from other sectors, Therefore, identifying the challenges and risks of outsourcing is essential for protecting service quality and equity [13]. This is particularly important in low- a (...truncated)