A total of 21 participants (11 males and 10 females) with a diverse range of responsibilities and experiences in the field of outsourced primary health services contributed to the study. The participants’ average age ranged from 23 to 52 years, with educational backgrounds from bachelor’s to doctoral levels. Participants represented three primary stakeholder groups: contractor company representatives, university-level administrators (employers), and frontline health workers (Table 1).
From the analysis of 1,150 open codes, 18 subthemes were identified and categorized into four main themes. (Table 2) This categorization is based on the widely-used Donabedian’s Structure–Process–Outcome (SPO) framework, which provides a robust model for evaluating the quality of healthcare. Each challenge was categorized based on its operational role and its level of influence within the framework.
In alignment with the SPO model, we categorized the challenges as follows:
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Structure Challenges: This category encompasses challenges related to the foundational resources and conditions required for outsourcing success. It includes Structural and Managerial Challenges, Economic Challenges, and Human Resources Challenges. These themes reflect issues with the organizational setup, financial resources, and the quality and stability of the workforce. all of which are fundamental structural components.
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Process Challenges: This category includes challenges related to the specific activities and procedures involved in delivering outsourced services. This includes sub-themes such as inefficient monitoring and performance evaluation systems, lack of transparency in contracts. These are the key operational elements that can compromise the quality of care.
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Outcome Challenges: This category reflects the final results of the outsourcing initiatives. It includes Service Quality and Outcome Challenges, with sub-themes such as decreasing the quality of service and moving away from the main purpose of outsourcing, which represent the ultimate consequences for stakeholders.”
Structural and managerial challenges
Lack of strong supporting legislation
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.
From the contractor’s perspective -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.”
From the employer’s perspective – Participant No. 6: “Right now, if the university’s board of trustees allows a 10-year contract with a private company, the National Audit Office intervenes and says, ‘Why did you sign a 10-year contract when you could’ve held ten separate tenders to potentially transfer services to the private sector at a lower cost?’ If this law is passed by Parliament, then the National Audit Office will no longer be able to challenge such decisions. We need strong legal frameworks to support outsourcing.”
Human resources -Participant No.2 “We don’t have strong legal protection. If any issue arises, no one stands behind us—especially when we protest about our wages or working conditions. Neither the company nor the university supports us or defends our position.”
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 [20]. The participants in the interview stated in this regard.
From the contractor’s perspective – Participant number 12: “Corporate personnel are recruited and selected by the university and work in the company. On the one hand, since the personnel is our company and receives a salary from us, they must be accountable to us and strive to achieve our goals. On the other hand, they must also be accountable to the university. Each employee has several bosses and receives orders from several bosses, and sometimes the orders of these bosses conflict with each other.”
From a human resources perspective-Participant No. 8: “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.”
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.
From the employer’s perspective-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.”
From a human resources perspective –Participant No.11: We have no choice; we must work with the company currently in place. Since this is the only contracting company operating in this field, we have no alternatives. Whatever conditions they impose, we’re forced to accept them.
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.
From the employer’s perspective -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.”
From the contractor’s perspective– Participant No.13: “When signing a contract, there’s no clear or consistent process. Each university—and even each year as the board of directors’ changes—sets different regulations. For instance, in this term under Mr. X’s presidency, one service is outsourced and a new set of responsibilities and rules are imposed on the contracting company. In the next term, when the president changes, the rules may shift again based on the new president’s views. Moreover, outsourcing the same service might follow one set of regulations at a university, while in a neighboring province’s university, the very same service is outsourced under entirely different rules and obligations.”
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.
From the employer’s perspective -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.”
From the contractor’s perspective- Participant No.18: The contract clauses are open to interpretation. When the university drafts the contract, the provisions are written in a vague and generalized manner. So, when challenges arise, the university offers different interpretations to avoid legal responsibility and shifts the meaning in its favor.
Inefficient performance monitoring system
One of the key challenges faced by universities in outsourcing is the absence of a robust performance monitoring and evaluation system. Without reliable verification mechanisms, it becomes difficult to accurately assess the performance of private sector providers.
From the employer’s perspective -Participant 9: “Performance evaluation refers to the process of assessing the success or failure of staff activities based on predetermined performance indicators. In the absence of strong metrics, it’s impossible to make a fair judgment about success or failure.”
From the contractor’s perspective- –Participant NO.3:“The performance evaluation indicators that have been defined are imprecise and influenced by personal preferences.”
Economic challenges
Low profitability
The next challenge was the low profitability. Due to the low pricing of outsourcing contracts, the amount paid to the company—after deducting expenses and paying staff salaries—leaves only a small sum as managerial profit for the companies. Compared to the challenges and complications associated with outsourcing, this amount is extremely limited and has significantly reduced the incentive for private sector participation in outsourcing initiatives.
From the employer’s perspective -Participant No. 15: ““With the limited resources allocated for outsourcing, our budget is quite restricted. The payment made to companies through outsourcing contracts yields little profit for them. As a result, our bargaining power is significantly weakened, reducing our influence in outsourcing arrangements.”
From the contractor’s perspective- Participant No.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.”
Unfair valuation of services
During the implementation of service purchasing and pay-for-performance schemes, one of the most critical issues to address is the valuation of services. Through this process, we can achieve greater transparency in services and their value, paving the way for proper outsourcing. However, participants indicated that, at present, service valuation is being conducted unfairly.”
From the contractor’s perspective 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.
From a human resources perspective -Participant No. 14 : “The tariffs set for services in the healthcare sector are not realistic. Different services vary in terms of workload and difficulty, yet they’re assigned equal tariffs and valued uniformly. As a result, we end up working much more than what we’re compensated for.”.
Short-term contracts – feeling temporary
Pursuant to the directives issued by the Ministry of Health and the National Inspection Organization, outsourcing contracts in the healthcare sector must be limited to a one-year term. This policy is intended to facilitate annual bidding processes, thereby allowing capable companies offering competitive pricing to participate. However, this short-term contractual framework has inadvertently fostered a perception of instability among service providers. Contractors frequently express concerns regarding the temporary nature of their engagement, which constrains their strategic planning and discourages long-term investment.
From the contractor’s perspective-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.”
From a human resources perspective -Participant No. 11: “The companies sign one-year contracts with the university, so the contracts issued to us are also for one year. Each year, we live with the fear that the company may not return the next year, and we could end up unemployed”.
Lack of decision-making authority and financial independence
One of the most significant challenges in outsourcing initiatives has been the lack of decision-making authority and financial autonomy. This constraint has hindered the alignment of current outsourcing practices with the fundamental principles of effective delegation. In this regard, several participants noted:
From the employer’s perspective -Participant No. 10 : “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.”
From the contractor’s perspective-Participant No. 13: “When the company does not have the right to make decisions and practical independence in any field, it cannot have management.”
Economic instability
Economic instability in the country—including severe currency fluctuations, continuously rising costs, and the absence of a stable financial outlook—is a key factor undermining the effective implementation of healthcare service outsourcing. Such instability disrupts the efficacy of contracts, budgets, and medium- to long-term planning processes. The literature highlights that economic volatility poses a serious threat to the sustainability and quality of health services delivered by the non-governmental sector [21].
From the contractor’s perspective-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.”
From the contractor’s perspective:- Participant No.18: “Due to unstable economic conditions and the continuous rise in prices, our budget constraints have become a serious obstacle to signing new contracts with private contractors. The outsourcing payments we propose are deemed unacceptable, as they fail to align with the contractors’ current operational costs. Moreover, sudden and significant price fluctuations disrupt the contractors’ cost management, potentially leading to a decline in the quality and quantity of services delivered. As a result, we are frequently compelled to amend contracts and raise the allocated budget in order to maintain service quality.”
Human resources challenges
Insufficient motivational mechanisms
Motivation is an internal driving force that determines the intensity, direction, and persistence of an individual’s effort toward achieving a goal [22]. In other words, it is an inner state that generates energy and defines the direction and magnitude of behavior aimed at fulfilling a need [23]. Effective organizational management requires that managers, by understanding and anticipating the motivations of their workforce, actively strive to meet their needs appropriately and timely—thereby creating the conditions for genuine engagement and productivity aligned with organizational goals [24]. In this regard, participants stated:”
From the contractor’s perspective-Participant No. 3: “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.
From a human resources perspective- Participant No. 2 : “For contracted personnel, there are no specific reward items defined. Beyond our basic salary, we receive no additional benefits. As a result, we have no motivation to work harder or perform better. In fact, we have no incentive to remain in this position at all.”
Lack of job security
Perceived job security is defined as the sense of safety regarding the preservation and continuity of one’s employment. It is considered one of the key manifestations of feeling secure and, following physiological needs, constitutes the strongest level of human motivation [25]. In the workplace, this need is fulfilled by assurance of continued employment [26]. In essence, perceived job security reflects an individual’s assessment of personal, organizational, and environmental conditions, leading them to the conclusion that no particular factor threatens their job stability—and that they can confidently rely on continued employment both now and in the future. If organizations fail to incorporate modern concepts of job security, they will not be able to achieve adequate efficiency and effectiveness in employee performance. Job insecurity undermines employee empowerment across specialized competencies, practical initiative, experiential learning, job satisfaction, work ethics, and promotion opportunities. As a result, organizations are unable to meet their specialized and social expectations [27]. In this regard, several participants stated:”
From the contractor’s perspective-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.”
From a human resources perspective -Participant No. 16: “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.”
Workforce instability
One of the key challenges in the implementation of outsourcing in primary healthcare services is the high rate of staff turnover and attrition within contractor-managed facilities. Human resource instability can lead to diminished service quality, reduced public trust, and increased training and management costs for both contractors and commissioning authorities.
International studies have also highlighted that workforce instability—particularly within outsourced structures—results in job dissatisfaction, weakened continuity of care, and inefficiencies in healthcare delivery [28]. In the conducted interviews, this challenge was discussed from multiple perspectives:”
From the employer’s perspective -Participant No. 19: “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.”
From a human resources perspective – Participant No. 8 :When there’s no guarantee for job continuity, it’s only natural to move on if a better opportunity comes along. This job lacks stability.
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” [29]. 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 [30]. This issue was raised as one of the challenges of the workforce and in this regard the participants had the title.
From a human resources perspective-Participant No. 20: “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.”
From a human resources perspective-Participant No. 11: “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.”
Reluctance of specialized medical and dental professionals to work in outsourced healthcare sectors
In addition to challenges arising from the limited engagement of private sector applicants in outsourcing initiatives, the recruitment of specialized personnel—particularly physicians and dentists—in underserved and remote regions poses a significant challenge for university-affiliated health services, due to the low attractiveness of such positions.
From the employer’s perspective-Participant No. 3: “The payment amount specified in the instruction (executive instruction for the provision and promotion of primary health care in urban and rural areas) is very low. As a result, general practitioners and dentists show no interest in joining. This makes it extremely difficult for us to recruit doctors for these regions. Those who do come don’t stay long because the working conditions and pay are unstable.”
Service quality and outcome challenges
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.
From the employer’s perspective -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.”
From the contractor’s perspective – Participant No.4: “The university’s current focus in outsourcing is solely on costs and the quantity of services. The emphasis on expenses is so strong that quality is essentially overlooked.”
Decreasing the quality of service
One of the significant and concerning consequences of outsourcing healthcare services is the decline in the quality of services provided to the community. Although outsourcing begins with the goal of increasing efficiency, expanding service coverage, and improving quality, in practice, the lack of effective supervision, unstable financial incentives, workforce instability, and resource limitations may lead to a noticeable decrease in the quality of care.
Numerous studies have shown that without careful contract design, weak oversight, and financial pressures, outsourcing can lead to diminished professional standards and lower client satisfaction [8]. In this regard, the participants stated that:
From the employer’s perspective -Participant No.1: “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.”
From the contractor’s perspective Participant No.12: “We try to maintain quality, but when resources are limited and the staff is unmotivated and constantly changing, it’s difficult to sustain it.”