The relative efficiency of public and non-public health centres in Iran
Given the focus of Iran's government on primary health care (PHC) in recent decades in
order to address the public health of the entire population, it has been said that the
country's primary health network has achieved much in this period so that it is now one of
the best PHC systems in the region as well as in the developing countries. Nevertheless,
this publicly funded and provided PHC system is currently faced with many problems
particularly financial restrictions, inefficiency, under utilisation and low motivated staff.
Market based reform has been used to address these issues. Privatisation is such a use of
marketisation, which has been used, in the whole public sector in Iran in recent years.
Currently, market based reform is the approach of the government in order to use the
opportunities of private sector in the health care delivery as well as in PHC services and its
The policy reform agenda, contracting with the private-for-profit sector is one of the
strategies of reform in the PHC sector to expand the PHC network, started in 1999 in East
Azerbaijan Province (EAP) and followed in other provinces later.
In the EAP initiative, there are nine non-public urban health centres providing the defined
package of PHC for about 140,000 urban population in the three different cities. All these
health centres with a matched group of nine public health centres were compared in this
The comparison has focused on the economic performance of the health centres including
technical input efficiency, input allocative efficiency (cost efficiency and the efficient mix
of inputs) and overall input economic efficiency as a combination of `technical input' and
`input allocative' efficiency.
There is a broad definition for the term efficiency, which includes customer satisfaction as
an outcome indicator and were measured among a sample of attendants in each group.As cost effectiveness, linking between cost and consequenceso f health care, of public and
non-public health centres in the delivery of primary health care was part of this
investigation, that required justifying the comparability of outcomes of provided care by
the health centres of two groups. The justification was given about the comparability of
outcomes of preventive care in both sectors given the characteristics of their services.
However, for curative care and as a tracer condition, the health status change measurement
among a sample of follow up patients visited by the GPs in each group was measured by
using EQ-5D questionnaire, to justify the comparability of outcomes of curative care
between the two groups of study.
To triangulate i. e. complementation and confirmation of the results of efficiency and
outcome measurement, a sample of key health staff and experts as well as all managers of
study health centres was approached to reveal their viewpoints about the different aspects
of such interventions. This could indicate the extent to which the viewpoints and realities
are or are not consistent and can potentially bring some issues that probably were omitted
in the other parts of this research but are initially important to these key health experts.
The result of this study has revealed that the non-public sector in all dimensions of
economic indicators in terms of technical input efficiency, input allocative efficiency (both
cost efficiency and efficient mix of inputs) and then overall input economic efficiency had
significantly (P value S 0.05) higher scores than the public sector.
Also, the result of customer satisfaction survey has shown that a significantly (P value S
0.05) higher level of customers in the non-public sector are satisfied with the performance
of health centres than the customers in the public sector; however, the level of customer
satisfaction in both groups was high.
The result of health status change measurement did not reveal any significant differences
between the two groups in terms of the impact of provided curative care. This, together with the given justification about the comparability of preventive care in the two sectors,
provided the basis for the cost effectiveness comparison in the delivery of PIIC between
the groups of study.
The result of cost effectiveness comparison has indicated that, given the comparability of
the outputs and the costs attached to the production, the non-public sector was significantly
(P value :50.05) more cost effective in the provision of PHC than the public sector.
Furthermore, the viewpoints of key health staff and experts as well as the managers of
study health centres were in line with the above realities.
The above findings have provided the evidence supporting the possibility of using existing
private sector opportunities in the provision and expansion of PHC in the urban area in Iran
and were interpreted as a possibility in Pareto improvement in the status quo of primary
health care delivery in this country. Given the financial limitation facing the current PHC
network in this country, it is concluded that public-private mix i. e. contracting with the
private sector such as that experienced in the EAP is a way forward to support PHC
provision for the urban area in Iran.