Outsourcing in University Hospitals to Provide a Policy Formation Model: A Meta-Synthesis

Document Type : Review Article


1 PhD in Management, Decision Making and Public Policy, Urmia University of Medical Sciences, Urmia, Iran.

2 Associate Professor, Department of Management, Central Tehran Branch, Islamic Azad University, Tehran, Iran

3 Assistant Professor, Department of Management, Central Tehran Branch, Islamic Azad University, Tehran, Iran



Introduction: Every organization needs to develop and use the opportunities and mechanisms to resolve its issues and problems, improve conditions, and take advantage of new opportunities and mechanisms. The health sector, particularly educational and health centers, is not an exception and is more important in terms of its role in enhancing people's health. Thus, the objective of this study was to provide a model for the formation of outsourcing policies in educational centers
Methods: This study used an integrative meta-synthesis approach based on the model presented by Sandelowski and Barroso. For data collection, national and international scientific databases were searched to find researches conducted from January 2010 to August 2019 using the following keywords: outsourcing, hospital outsourcing, outsourcing policy formation, outsourcing policy-making in hospitals of internal and external were used. Finally, 37 articles were selected.
Results: A total of 10 main categories and 34 subcategories were identified by reviewing selected articles including outsourcing causes and objectives (five subcategories), outsourcing challenges (five subcategories), outsourcing disadvantages (five subcategories), outsourcing advantages (four subcategories), selection options (two subcategories), opportunities (three subcategories), risks (four subcategories), direct stakeholders (two subcategories), indirect stakeholders (two subcategories), and decision-makers (actors) (two subcategories). Finally, an outsourcing policy formation model was presented.
Conclusion: The results of this study indicated the influence of different components and dimensions on the formation of outsourcing policy in the University Hospitals. Therefore, if the policy-makers have a comprehensive and realistic viewpoint, they can play a significant role in the success of the policies formulated.



    1. Murthy P, Ansehl A. Technology and global public health. New York: Springer; 2020. p. 88.
    2. Kelly N, Garvey J, Palcic D. Health policy and the policymaking system: A case study of primary care in Ireland. Health Policy. 2016; 120(8):913-9. doi: 10.1016/j.healthpol.2016.06.006.
    3. Benner M. Mitigating human agency in regional development: the behavioral side of policy processes. Regional Studies, Regional Science. 2020; 7(1):164-82. doi:10.1080/21681376.2020.1760732.
    4. Brynard P. Policy implementation: lessons for service delivery. Journal of Public Administration. 2005; 40(3):649-664. doi: 10.10520/EJC51437
    5. Danaesfahani Z, Taherpour H. identifying the factors influencing the execution of chapter 9 of services management act. Journal of Development Evolution Management. 2013; 11(11):33-49. [In Persian].
    6. Ghanbari Hamadani S. Policy from formulation to implementation with the approach of examining the barriers to full implementation of public policy from the perspective of experts. 3rd National Conference of New Researches in the Field of Humanities and Social Studies in Iran, 8 August 2019, Soroush Hekmat Mortazavi Center for Islamic Studies and Research, Qom; 2017. [In Persian].
    7. Alvani SM, Ahmadi K. the concept of corporate social responsiveness and the necessity of explaining its factors at iran’s public organizations. Quarterly Journal of Public Organizations Management. 2013; 1(3):8-16. [In Persian]. doi :20.1001.1.2322522.1392.
    8. Dehdashti Shahrosh Z, Parishan F, Taghavizadeh F. Identify key factors affecting service outsourcing. in Iran. Conference: International Conference on Management, Culture and Economic Development, May 20, 2015, Raymand Pajooh Research Institute, Mashhad; 2015. [In Persian].
    9. Ferdosi M, Farahabadi E, Mofid M, Rejalian F, Haghighat M, Naghdi P. evaluation of outsourcing in nursing services: a case study of kashani hospital, Isfahan in 2011. Mater Sociomed. 2013; 25(1):37–9. doi: 10.5455/msm.2013.25.37-39.
    10. Ravaghi H, Salari Hamzehkhani M, Aryankhesal A. Designing a tool for evaluation of the outsourcing process in laboratories of non-educational hospitals. Health and Development Journal. 2019; 7(4):353–67. [In Persian]. doi: 10.22034/7.4.353.
    11. Barik SK, Rout HS. Outsourcing of healthcare services in a smart city of Eastern India. Journal of Facilities Management; 2021. (ahead-of-print.) doi: 10.1108/JFM-02-2021-0018.
    12. London JD. The promises and perils of hospital autonomy: reform by decree in Viet Nam. Soc Sci Med. 2013; 96:232-40. doi: 10.1016/j.socscimed.2013.07.009. 
    13. Markazi-Moghaddam N, Aryankhesal A. Arab M. The first stages of liberalization of public hospitals in Iran: establishment of autonomous hospitals and the barriers. Iranian Journal of Public Health. 2014; 43(12):1640-1650.
    14. ‌Maharani A, Femina D, Tampubolon G. Decentralization in Indonesia: lessons from cost recovery rate of district hospitals. Health Policy Plan. 2014; 30(6):718-727. doi: 10.1093/heapol/czu049.
    15. Maharani A, Tampubolon G. The double-edged sword of corporatisation in the hospital sector: evidence from indonesia. Health Econ Policy Law. 2017; 12(1):61-80. doi: 10.1017/S174413311600027X.
    16. Abdullah MT, Shaw J. A review of the experience of hospital autonomy in Pakistan. Int J Health Plann Manage. 2007; 22(1):45-62. doi: 10.1002/hpm.855.
    17. Sepehri A. Does autonomization of public hospitals and exposure to market pressure complement or debilitate social health insurance systems? Evidence from a low-income country. Int J Health Serv. 2014; 44(1):73-92. doi: 10.2190/HS.44.1.e.
    18. Doshmangir L, Rashidian A, Jafari M, Ravaghi H, Takian A. Fail to prepare and you can prepare to fail: the experience of financing path changes in teaching hospitals in Iran. BMC Health Serv Res. 2016; 16:138. doi: 10.1186/s12913-016-1405-7.
    19. Alizadeh Z, Torabipour A. The obstacles of outsourcing in educational hospitals: a qualitative study. Journal of Qualitative Research in Health Sciences. 2020; 7(2):204–13. [In Persian].
    20. Raus K, Mortier E, Eeckloo K. Past, present and future of university hospitals. Acta Clin Belg. 2020; 75(3):177-184. doi: 10.1080/17843286.2019.1590024.
    21. Kavousi Z, Setoudehzade F, Kharazmi E, Khabiri R, Ravangard R, Rahimi H. The level of propensity to outsource Study: Based on hospital services features by managers and staff perspective in hospitals Kavousi Z Abstract: of Shiraz University of Medical Science, 2010. Journal of Hospital. 2012; 11‌(1):9-18. [In Persian].
    22. Joudaki H, Heidari M, Geraili B. Outsourcing of Hospitals Services: Lessons Learned from the Experience. Health_Based Research. 2015; 1(1):13-23.
    23. Chandra H. financial management analysis of outsourcing of the hospital services for cost containment and efficiency: case study of sanjay gandhi post-graduate institute of medical sciences, Lucknow, India. Journal of Financial Management and Analysis. 2007; 20(1):82-91.
    24. Liu X, Hotchkiss DR, Bose S. The impact of contracting-out on health system performance: a conceptual framework. Health Policy. 2007; 82(2):200-11. doi: 10.1016/j.healthpol.2006.09.012.
    25. Komatsu M. Advantages and disadvantages of outsourcing hospital microbiological testings. Rinsho Byori. 2011; 59(10):944-6.
    26. Raeissi P, Sokhanvar M, Kakemam E. Outsourcing in Iranian hospitals: Findings from a qualitative study. Int J Health Plann Manage. 2018; 33(4):1250-1261. doi: 10.1002/hpm.2619.
    27. Olofsson PT, Aspelin P, Bohlin J, Blomqvist L. The impact of contracts on outsourcing computed tomography examinations from a Swedish public university hospital to a private radiology unit. Radiography (Lond). 2019; 25(2):148-154. doi: 10.1016/j.radi.2018.12.014.
    28. Mousavi H, Khodamoradi F, Rostami Zarinabadi CH, Mozafar Saadati H, Mohammadi M, Mahboubi M, Mousavi N. The effect of radiology services outsourcing on patients' satisfaction in Tehran city hospitals. J Med Life. 2015; 8(Spec Iss 3):31-35. 
    29. Mehdizadeh P, Dopeykar N, Gol-Alizadeh E, Yaghoubi M. the status of outsourcing services in a specialized tehran hospital using swot. Hospital Practices and Research. 2016;1(3):95–99. [In Persian]. doi: 10.20286/hpr-010395.
    30. Souza HS, Mendes ÁN. Outsourcing and "dismantling" of steady jobs at hospitals. Rev Esc Enferm USP. 2016; 50(2):286-94. doi: 10.1590/S0080-623420160000200015. [In Persian].
    31. 31. Hejazifar S, Rahnavard F, Latifi M, Taherpourkalantari study of Islamic governance in Iran using the meta-synthesis method. Quarterly Journal of Public Organzations Management. 2018; 6(1):63-82. [In Persian]. doi: 20.1001.1.2322522.1396.
    32. 32. Sandelowski M, Barroso J. Handbook for synthesizing qualitative research. springer publishing company; 2006. P. 312.
    33. Khoshouei M S, Oreyzi H R. Developing integrated cycle for implementing experience management in organizations. Iranian Journal of Information processing and Management. 2018; 33(4):1477–1508. [In Persian].
    34. Glynn L. A critical appraisal tool for library and information research. Library Hi Tech. 2006; 24(3):387-399. doi: 10.1108/07378830610692154.
    35. Manzoor F, Wei L, Hussain A, Asif M, Shah SIA. Patient satisfaction with health care services; an application of physician’s behavior as a moderator. Int J Environ Res Public Health. 2019; 16(18):3318. Doi: 10.3390/ijerph16183318.
    36. Mujasi PN, Nkosi ZZ. Exploring perceptions, motivations, and practices regarding outsourcing support services by general hospitals in Uganda: A mixed methods study. Int J Health Plann Manage. 2019; 34(2): 1272-1292. doi: 10.1002/hpm.2773.
    37. Moslehi S, Atefimanesh P, Sarabi Asiabar A, Ahmadzadeh N, Kafaeimehr M, Emamgholizadeh S. Does outsourcing paramedical departments of teaching hospitals affect educational status of the students? Med J Islam Repub Iran. 2016; 30:404.
    38. Omrani M, Mostafavi H, Khazar S, Ghalami S, Farajzadeh F. laboratories performance after outsourcing in the hospitals of shahid beheshti university of medical sciences. Medical Laboratory Journal. 2013; 7(2):42-48.
    39. Mrak RE, Parslow TG, Tomaszewski JE. Outsourcing of Academic Clinical Laboratories: Experiences and Lessons from the Association of Pathology Chairs Laboratory Outsourcing Survey. Acad Pathol. 2018; 5:2374289518765435. doi: 10.1177/2374289518765435.
    40. 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 Islam Repub Iran. 2018; 32:56. doi: 10.14196/
    41. Mujasi PN. Practices, motivation, perceived benefits and barriers to outsourcing by hospitals in Uganda. (Doctoral dissertation). University of South Africa; 2016.
    42. Czerw AI, Kowalska M, Religioni U. Differences in the use of outsourcing in public and private institutions providing medical services. Arch Med Sci. 2014; 10(3):618-29. doi: 10.5114/aoms.2014. 43754.
    43. Toffolutti V, Reeves A, McKee M, Stuckler D. Outsourcing cleaning services increases MRSA incidence: Evidence from 126 english acute trusts. Soc Sci Med. 2017; 174:64-9. doi: 10.1016/j.socscimed.2016.12.015.
    44. Shaarbafchizadeh N, Aghdak P, Sahebi M. Outsourcing in health facilities: challenges in medical university of isfahan in focus. Int J Prev Med. 2020; 11:172. doi: 10.4103/ijpvm.IJPVM_196_20.
    45. Mousazadeh Y, Jannati A, Jabbari Beiramy H, Asgharijafarabadi M, Ebadi A. Advantages and disadvantages of different methods of hospitals' downsizing: a narrative systematic review. Health Promot Perspect. 2013; 3(2):276-87. doi: 10.5681/
    46. Mehregan M, Salami H, Khajeh M. presenting a multi attribute decision making model: outsourcing the business processes with employing analytical network process (ANP). Journal of Development and Transformation Management. 2011; 6(6):17–30. [In Persian].
    47. Saeidpour J, Faridfar N, Ghaziasgar M. Factors affecting the implementation of outsourcing in Tehran University of medical sciences hospitals: hospital administrators’ vision. Journal of Payavard Salamat. 2019; 13(2):142-150. [In Persian].
    48. Niknam N, Gorji HA, Langarizadeh M. The challenge of outsourcing of hospital services in Iran: A qualitative study. J Educ Health Promot. 2020; 9:294. doi: 10.4103/jehp.jehp_132_20.
    49. Barati O, Najibi M, Yusefi AR, Dehghan H, Delavari S. Outsourcing in Shiraz university of medical sciences; a before and after study. J Egypt Public Health Assoc. 2019; 94(1):13. doi: 10.1186/s42506-019-0010-0.
    50. Hsiao CT, Pai JY, Chiu H. The study on the outsourcing of Taiwan's hospitals: a questionnaire survey research. BMC Health Serv Res. 2009; 9:78. doi: 10.1186/1472-6963-9-78.
    51. Moschuris SJ, Kondylis MN. Outsourcing in public hospitals: a Greek perspective. J Health Organ Manag. 2006; 20(1):4-14. doi: 10.1108/14777260610656534.
    52. Sclar ED, Leone RC. You don’t always get what you pay for: the economics of privatization (A Century Foundation Book). New York: Cornell University Press; 2001.
    53. 53. Barthelemy J. The seven deadly sins of outsourcing. Academy of Management Perspectives. 2003; 17(2):87-98. doi.org/10.5465/ame.2003.10025203.
    54. 54. Barthelemy J. The hidden costs of IT outsourcing. Mit Sloan Manage Rev. 2001; 42(3):60-69.
    55. Rasi V, 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. Tamin-e-Ejtemaie. 2018; 14(3):117–34. [In Persian].
    56. Ahmadi Zadeh E, Tajvar M, Ahmadi A, Ahmadi B. Challenges of Outsourcing in Hospitals Affiliated with Tehran University of Medical Sciences and Suggested Solutions. Health Based Research. 2018; 4(1):77-93. [In Persian].
    57. Aliabadi E, Azizi M, Aalam TA, Davari A. identifying the barriers in implementing entrepreneurship and innovation policy in development plans of the Islamic republic of Iran. Journal of Innovation and Creativity in Human Sciences. 2019; 8(3):95-132. [In Persian].
    58. Mohammadi Fateh A, Danaee Fard H, Rahnavard F, Foroozandeh L. Designing a Model for Promoting Policy-making Capacity in the Executive Branch of Iran Public Administration. Journal for Management and Development Process. 2016; 29(3):3-38. [In Persian]. ‎ doi: 20.1001.1.17350719.1395.
    59. Tezera D. Factors for the successful implementation of policies. Merit Research Journals of Education and Review. 2019; 7(8):92-5. doi: 10.5281/zenodo.3382780.
    60. Hudson B, Hunter D, Peckham S. Policy failure and the policy-implementation gap: can policy support programs help? Policy Design and Practice. 2019; 2(1):1-14. doi: 10.1080/25741292.2018.1540378.
    61. Bjorvatn K, Søreide T. Corruption and privatization. European Journal of Political Economy. 2005; 21(4):903–914. doi: 10.1016/j.ejpoleco.2005.02.001.

    62.        Bortolotti B, Faccio M. Government control of privatized firms. The Review of Financial Studies. 2009; 22(8):2907–39. doi: 10.1093/rfs/hhn077