• Amirhossein Takian, Arash Rashidian, and Leila Doshmangir.
• Department of Global Health and Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, National Academy of Medical Sciences, Tehran, Iran, College of Health and Life Sciences, Brunel University London, Uxbridge, UK, takian@tums.ac.ir takiana@gmail.com.
• Health Policy Plan. 2015 Dec 1; 30 (10): 1261-71.

BackgroundThe Iranian health system, under the banner of family physician (FP) programme, has undergone substantial reforms to change utilization of health services, improve quality of care and enhance affordability. The national implementation of FP initiated in 2005 in parallel with rural health insurance (RHI) in rural areas and cities of <20 000 populations in Iran. The implementation of FP was the first national attempt to split the purchaser and provider of the primary health-care services in Iran. Using an adapted institutional approach, this article aims to explore the process of purchaser-provider split (PPS) during the implementation of FP and RHI reforms, and its consequences for the health system in Iran.MethodsWe conducted 71 face-to-face interviews and three focus group discussions at national, provincial and local levels with policy makers, managers, researchers, health-care practitioners and representatives of the public. Interviews and focus groups were digitally recorded and transcribed verbatim. Data collection was supplemented by the review of relevant documents at all three levels. We analysed the data using an inductive-deductive framework analysis approach.ResultsViews towards PPS and its consequences on the implementation of FP were diverse. Some participants identified the PPS as an essential reform for undertaking the parallel implementation of FP and RHI. Others wondered whether the split has been beneficial as expected and asked for more scrutiny.ConclusionsThe implementation of FP and RHI in Iran demonstrated the mixed effects of PPS on health system performance. Our research revealed that PPS did not succeed in changing the status quo, became a reason for fighting, misunderstanding, lack of co-operation and failure of the fragile partnership between the purchaser and provider. We advocate careful contextual preparation prior to large-scale application of PPS during nationwide implementation of FP in Iran as well as other settings.Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2015; all rights reserved.

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