title: The experience of purchaser-provider split in the implementation of family physician and rural health insurance in Iran: an institutional approach.
abstract: BACKGROUND
  The 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.
  
  
  METHODS
  We 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.
  
  
  RESULTS
  Views 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.
  
  
  CONCLUSIONS
  The 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.
authors.affiliation: 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.
authors.forename: Amirhossein
authors.initials: A
authors.lastname: Takian
authors.affiliation: Department of Global Health and Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Arash
authors.initials: A
authors.lastname: Rashidian
authors.affiliation: School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran and Iranian Center of Excellence in Health Management, Tabriz University of Medical Sciences, Tabriz, Iran.
authors.forename: Leila
authors.initials: L
authors.lastname: Doshmangir
mesh_terms: D005194:Family Practice / Q000458:organization & administration*; D017144:Focus Groups; D006268:Health Facilities; D006291:Health Policy; D006801:Humans; D007348:Insurance, Health; D007492:Iran; D011320:Primary Health Care / Q000191:economics / Q000458:organization & administration*; D019035:Rural Health Services / Q000458:organization & administration*
keywords: Family physician (FP); Iran; purchaser–provider split (PPS); rural health insurance (RHI)