Identifying Barriers to Development of the Public-Private Partnership in Providing of Hospital Services in Iran:A Qualitative Study

Background: In recent years, public-private partnerships (PPPs) have been used to expand hospital services in many countries. Despite the achievements and implications, there have always been many challenges in implementing it. The purpose of this study was to identify the barriers and challenges in the development of public-private partnerships in hospital services in the country of Iran. Methods : This is a qualitative study conducted in 2015- 2016 by the content analysis method. The research population included experts and health professionals and those who have contributed to the development of PPPs model in hospital services (public and private). Of these, eighteen were selected using a purposive sampling approach and were interviewed semi-structured. The MAXQDA 10 software was used to analyze the transcribed interviews. Results : Four main themes and sixteen sub-themes were identified concerning the barriers to developing public-private partnerships in the provision of hospital services in the country. They are cultural and social barriers, political and legal barriers, financial and investment barriers, and structural and process barriers. Conclusion : Officials and policymakers should identify the obstacles facing participatory patterns and then provide a suitable platform for nongovernmental organizations. This action can lead to an increase in the level of readiness of hospitals in Iran to implement this model.


Introduction
ccording to the experience, governments cannot alone afford the health sector expenditureand provide high-quality services because they face budget constraints for providing services and there are inefficient and improper management, inefficiency, longtime and high cost, and low quality of services in the public sector; hence, it is reasonable to assume that the public-private partnershipsproduce more favorable outcomes (1,2).
The public-private partnership (PPP) model, which was introduced in 1990, has been widely used for constructive reformsof health sectorsin several countries (3). PPP is an effective approach to cope withthe enormous challenges of the health sector in the twenty-first century (4). PPPseeks to apply some principles of the private sector, including the economic equilibrium and revenues through coherent financial management to solve some significant problems in the public sector (5). In a natural competition for providing health services, public and private sectors are always attracting by healthcare seekers and income earning.This competition can be converted into partnership in the PPPto overcome constraints of each sector (6). PPP is a contractual agreement between a governmental institution and the private sector whereby the capabilities and assets of each sector are shared to provide services and facilities for the public. Furthermore, potential risks and benefits of facilities and services are shared between parties. Reducing governmental responsibilities and increasing the government's ability to plan, set standards, finance and legislate, taking responsibility for financing investments from the government, using the competition element to increase efficiency, increasing the autonomy of management and decentralization of decision making to executives are some benefitsofthe public-private partnership in hospitals (7,8).
Despite the fact that the PPP implementation has many achievements and outcomes, there are always many challenges forits implementation. Problems and challenges of the PPPimplementationin the Canadian Health Department include misconceptions about the public sector, trade union opposition, and longterm contractual nature of PPP (4). Other constraints and challenges of the PPP implementation include the weak coordination between different governmental sectors, resistance to the general interest, excessive delays due to administrative, bureaucratic procedures, and the pace of changes in the healthcare sector (4,9).
Private sector participation in public hospitals has several typesranging from easy support service contracts to complex stages of designing, building, and managing hospital facilities.Each of these modelshas different types of hospital ownership and management, responsibility for design and construction, as well as investment, business risks, and contract duration (2,10,11).
In Iran, Moheb nonprofit organization has provided areasonable basis for providing optimal healthcare service by the attitude tothe partnership of public and private sectors and achieving a desired participatory model to align public and private sector strengths and eliminate their weaknesses. This institute has been designing, constructing, financing, and operating new hospitals as a nongovernmental partner in the vicinity of Hasheminejad (Moheb Mehr), HazratFatemeh (Mohebe Kosar) and Mirza Kuchak Khan (MohebYas) hospitals.Despite the fact that the use of this model has positive changes on performance indicesin public hospitals (2,12,13), results of studies indicated that like many other countries, there are challenges and barriers to development and promotion of these partnership models in Iran leading tothe participation of public and private sectors in the provision of hospital services.The present study was conducted to investigate barriers and difficulties in implementing publicprivate partnerships in the development of hospital services. It is hoped that the results of the present study will help health sector policymakers to plan formodifyingfailuresof partnership models in hospitals to improve the existing status of health systems.

Materials and Methods
The present study was qualitative research, which was conducted by the content analysis method.The research population consisted of health experts and professionals and those people who werefamiliar with PPP models and played roles in the development of this model in-hospital services.Samples were selected using a purposive sampling approach and then interviewed.The sample size criterion ofthe study was similar to other qualitative studies until the information saturation level. Sampling was completed, where new codes were not obtained.Accordingly, interviews were conducted with 18 health system experts in the field of PPP. Among them, nineexperts were representatives of the public sector, and nine were representatives of the nonpublic sector ( Table 1).
The interview method was used to collect data.Semi-structured interviews were conducted, so that general questions were initially initiated for interviews that were conducted based on samples' responses. Interviews were conducted by setting appointments and location selection according to participants' views. After the necessary coordination, all interviews were conducted at the participant's workplaces, and they lasted for 30 to 90 minutes, depending on participants' preferences and conditions. Conducted interviews were collected according to participants' permission, and they were immediately implemented after the end of each session to be aware of data saturation time and increased accuracy and precision of text implementation.
The content analysis was used to analyze data of each stage. Qualitative content analysis is a specialized method in processing the scientific data and is applicable to determine the existence of certain words and concepts in texts to summarize, describe, and interpret data (14). To this end, interviewers implemented text of each interviewafter conducting each interview.The text of each interview was studied several times to gain a comprehensive understanding of them.Besides, the implemented text of each interview was given to interviewees to make their comments or modifications. Finally, the interview text was entered into MAXQDA 10 for classification, and then an original code was extracted.Final codes and research themes were extracted by the partnership and use of interviewees and the research team's views, and ultimately, themes were grouped in classes and subclasses.
Various strategies were used to strengthen results such as member checks, givingthe interview text and its commentary to participants, and receiving their comments and suggestions,the peer check, and the use of peer debriefing. Verification of implemented texts, codes, and extracted classes was conducted by two members of the research team that had no conflict of interest with the research.
In this research, ethics include the confidentiality of information, the right to withdraw from the research, and the informed consent of participants for interviewing and recording interviews while maintaining anonymity and confidentiality from the beginning to the end of the study. This study was approved in Research Ethics Committee of Shiraz University of Medical Sciences (Ethics No: IR.SUMS.REC.1394.S134).

Results
From 18 interviewees, all of them were male, and their mean age and work experience were 48 ± 8.94 and 23 ± 7.18, respectively. According to results, four main themes and 16 sub-themes aboutbarriers to the development of public-private partnershipswere identified in providing hospital services in Iran, as presented in Table 2.

1-Cultural and social barriers:
Cultural and social issues, including six subgroups, are significant problems and barriers to participatory models such as the PPP. Among these cases, negative attitudes towards the nonpublic sector and investors are among the most important cultural and social barriers according to participants' views. In this regard, a participant acknowledged that: "In other countries, if anyonesays I am an investor, others respect him and say that he is oursavior, but in Iran, there is not such a mentality. There are groups who think that everything is going to be private, and problems arearising" (P8).
Some people also believed that the public sector had a competitive perspective compared to the private sector.
It considered the private sector as a competitor, not a collaborator or participant."Even the government sees itself as a rival to private and nonprofit institutions (such as Moheb nonprofit institution)" (P4,P11).
Others also believed that there was no national will to do such partnership work in Iran.
"National determination is the first thing that will lead to this aim, but it does not exist in Iran. We do not want any legal requirements; there are many laws. We just want the belief. It should be at all levels of the ministry. In Iran, anyone decides and acts on its own decision" (P7).
Participants believed that public sector employees were accustomed to existing practices, and thus they would not tolerate risks of accepting private organizations; this could be a significant barrier to accepting partnership models in hospitals.
"Private company employees receive their salary, obtain their leave, so why should they Others believed that the public sector had fears that the private sector would reduce the government's governance and power, and thusit prevents the entry of non-public actors to the health sector.
"They feel that the entry of private sector endangers their governance and powerin hospitals. They do not want to take the responsibility of public hospitals to the private sector" (P15).

2-Political and legal barriers:
Political and legal barriers are other barriers to the implementation of a public-private partnership model. Contributors believed that there was no established and consolidated legal framework for such models in Iran. In this regard, an expert said: "First of all, we want a clear business plan, that is, a body law by which you can see the next ten years. It contains the government's tasks, and everything is obvious. We do not have such a plan yet".(P3) The red tape and a long process of obtaining permits were other barriers that most respondents referred to. People believed that processes were complex and prolonged, and the red tape prevented investors from entering the realm of invest in hospitals. "An investor who wants to invest in this sector will have a long, difficult way to get permission. It is not related to the individual violation; the arrangement of structures and rules makes people reluctant to invest in this sector" (P7).
Another group of contributors considered the existence of contradictory laws in different organizations as abarrier to this partnership."There is no legal security for these investments, and people, who are entering a hospital, a university or health centeras an island, will change their mindand exit the collection after one or two years due to more controversial rules" (P14).
The political system of Iran's economy was an important issue that was considered by many interviewees as abarrier to the successful implementation of participatory models in the health sector. In such a situation, investors will not be willing to invest. "Our economic system is political, and it thus leads to the non-trust in the future for the investment" (P5).
The non-cooperation of national institutions and organizations was another political and legal barrier. Individuals believed that the proper and successful implementation of participatory models required inter-sectoral cooperation and teamwork, and all organs and institutions should work together and participate.
"The minister now likes to develop this plan, but he is alone; the rest of organs are reluctant to do so, and do not want to disturb their peace" (P8,P17).

3-Structural and process barriers:
Structural and process barriers were the third group of barriers to the implementation of publicprivate partnerships. As mentioned in most interviews, the lack of codified code and transparent contractswere the most significant barriers to this field. In this regard, some experts believed that: "There are still no rules for purchasing services from the private sector; the identity and nature of these institutions are not confirmed, whether they are private or public; what tariffs they should use for working; whatare types of their structure; whether they should have a board of trustees, a board of directors, or a technical officer. We did not define anything. They fail in their work until these things are not obvious".(P13) The lack of a single insurance mechanism and transparent insurance issues is another barrier to the implementation of participatory models in hospitals. With such a mechanism, investors will not be willing to invest. In this regard, an expert believed: Most experts believed that the way of choosing partners and holding tenders is very tangible and timely, leading to investors' non-willing to enter this competition.
"I think that they should holdtenders in a competitive space, properly recognize tenderers, and quickly act. They often practice based on their tastes. It takes months to advertise, leading toinvestors' non-willing to invest" (P5).

4-Financial and capital barriers:
Financial and capital barriers were other important identified issues in the present study. From the participants' perspective, they were significant barriers to the implementation of public-private partnerships. This class consisted of three subclasses in which the lack of guaranteed purchase by the government was identified as a major barrier. Most participants believed that there should be government guarantees for return on investment and profits for investors. Otherwise, investors would not be willing to invest in the health sector. The investor's lack of investor security is another critical barrier to the implementation of participatory models. People believed that if there is not any safe environment for investors, people would not be willing to invest.
"Capital goes to a safe place with guaranteed profits and independent people. The infrastructure for this issue is our bigproblem. The security has not been provided for investment in Iran"(P11).

Cultural and social barriers
Negative thinking about the presence of non-public sector and its investors Lack of national belief, will and determination to do so Getting used to existing procedures and not accepting high risks Feeling of lost sovereignty and the fear of falling power in the public sector A competitive look to the non-public sector

Political and legal barriers
Lack of fixed legal structure and framework Bumpy rules, the red tape, and the long process of obtaining permission The existence of counter-laws in different organs Political economic system of Iran Non-participation of national institutions and organizations

Financial and investment barriers
Government's non-guaranteed purchase of services Investment-attracting institutions' unfamiliarity with the investment literature Investors' lack of confidence

Structural and process barriers
The lack of comprehensiveregulations and transparent contracts for partnership The lack of a single insurance mechanism and a proper tariff system Complex and long processes in bidding, selection of partners and contract Downloaded from jebhpme.ssu.ac.ir at 18:46 IRST on Wednesday September 30th 2020 Volume 4, Issue 3, September 2020; 162-71

Discussion
In the present study, problems and barriers of the public-private partnership implementation in the provision of hospital services were studied from health managers and professionals' viewpoints in the public and non-public sectors. Research results indicated that hospitals of Iranare faced with four main barriers in the process of implementing participatory models such as the PPP: cultural and social barriers, political and legal barriers, financial and investment barriers, and structural and process barriers.
Despitemany achievements of the PPP implementation in most countries, there are always many challenges and problems in its implementation.
Danaeifard et al. classified the main barriers to the lack of development of public-private partnerships participation in national projects, including economic-financial, political, legal, institutional-structural, process, strategic, executive, human, and social-culturalbarriers (15).
According to results, social and cultural barriers were the first barriers to the implementation of the PPP model, as mentioned in most interviews. The results of many similar studies in this field also indicated that attention to social and cultural dimensions would play an important role in the development of private sector partnerships and the promotion of PPP projects. It is essential to change public attitudes and beliefs and reform views on the presence and participation of the private sector, and non-consideration of the PPP implementation just as the privatization. The results of a study showedcultural problems and beliefs as barriers to the development of arrangements for the public-private partnership in Iran. The authors believe that the development of infrastructural projects with the PPP strategy requires a large volume of financing that cannot be achieved only by a company and it needs several companies to cooperate and participate as a consortium in these projects; however, due to the lack of a collaborative and participatory culture, the partnership and interaction of partners face with problems after a short term, due to the occurrence of disputes; and this is abarrier to the PPP developmentin Iran (15). Results of a study in Sri Lanka indicated that convincing business institutions and public hospitals to implement a PPP model had been the biggest challenge. Public hospitals have had the impression that the government is moving towards the privatization of public services in Iran (16). In the implementation of PPP projectsin Indonesia, public disputes were considered to be risk factors for the implementation of participatory projects (17).
Policies and laws and, in general, the sovereignty were put in the second category of barriers and problems affecting the PPP implementation. The results of various studies indicate that the inappropriate structure of laws and regulations is an essential barrier to the delivery of services in the health sector. Hewitt and Boardman (18) and Hsiao et al. (19) similarly referred to barriers to the law and regulations on the assignment (20). Sovereignty is the leading cause of providing services in any society, and thus, no real partnership can be established without providing a desirable political and legal environment. The creation of a coherent and appropriate legal framework, along with the credibility and transparency of the participation of various players, both politically and legally, are the main tasks of the sovereignty and can play very important and effective roles in the success of PPP projects (21). It is vital to design and formulate appropriate policies and rules for setting up a road map to implement PPP projects. Without a roadmap, there will be no mechanism for achieving goals and aspirations in real and coherent projects. Some governments useprivate-sector partnerships without developing a comprehensive policy design leading to inappropriate goals and a high probability of problems in projects (22). The existence of a credible legal structure, which supports interests of the non-public sector and property rights and recognizes commercial contracts in the international conventions governing these contracts,is a prerequisite for the implementation of PPP projects (23). It is believed that by introducing transparent laws and changing the existing attitude towards the private sector participation, governments can change the public thought to this fact that state-controlled assets can provide wider and higher-quality services for people by private sector investment and management. According to results of a research, the PPP was successful in India mainly due to the full government's legal and political support of such projects. In 1990, a PPP projectfailed in South Korea due to the lack of transparency between partners. Subsequently, the government considerably revised and improved legal frameworks and the political environment for the PPP (17).
Financial and investment issues were other cases that participants considered as barriers to the implementation of the public-private partnership. Sadeghi pointed out that private sector investors required appropriate incentives to participate in PPP projects on health. These incentives can include loans with reasonable interest, low-risk projects, and reasonable profitability. If these incentives are not provided, or they are in such a way that they do not motivateinvestors toinvest, investors will not be willing to enter such projects and will select other fields and areas for investment (24).
Ultimately, structural and procedural barriers are also identified asbarriers facing PPP models. Proper preparation for projects is the main pillar of the project success. Every countryselects PPP projects, relevant regulations, methods of holding tenders, and partners based on its circumstances and assets based on available attitudes and perspectives. Many countries have special legal tools of the PPP and probably refer to the process of preparing these projects in these legal tools. In countries where there are no specific rules for this partnership, governments use the adopted public procurement process in the country. Governments must be encouraged to identify and prioritize realistic goals for their public-private partnership policies. Governments should start with those projects that are most likely to succeed and be accepted and are more straight forward and more practical (22). We can never determine the same model for different projects because each project has its own financial, technical, and legal structure. The way and selection of project implementation method and precise creation of contract documents and the selection of general terms of a relevant treaty within its framework are strategic decisions that play significant roles in the continuation of the project and its success or failure.

Conclusion
In recent years, the PPP has been widely used in the health sector of many countries, but due to some challenges and barriers to such projects, a number of these projects have failed. Therefore, the identification of effective barriers the PPP implementation and taking measures to overcome themcan be effective in the success of such projects in the future. In the present study, culturalsocial, political-legal, financial-investment, and structural-process factors were identified as effective barriers to the PPP implementation in hospital projects. Therefore, Iran's managers and policymakers are suggested taking measures toovercome these barriers and provide and create a suitable platform for increasing the success of such participatory projects in developing hospital services.
Considering that the present study has collected information only through content analysis approach and interviews, it is suggested that by conducting case studies and action research, substantial obstacles to the implementation of participatory models in the development of hospital services in Iran Be identified