According to the results, compared to the private sector, the public sector has more acquaintance with the concept of PPP and also more willingness to participate in such partnerships. This is contrary to the results of a study conducted in Sri Lanka, which showed that government officials had insufficient knowledge about PPP . On the other hand, our study found the private sector to be apathetic toward participating in the public sector. There are many factors that make investment in the healthcare sector barely cost-effective and push the investors away to available alternatives. Two of these factors is the high uncertainty of return on investment and low profit in this area, which undermine the willingness of private investors to take risks. Another issue is the state imposition of unrealistically low prices for services, which poses a serious threat to the profit. Some believe that after privatization or delegation of state-run healthcare services to the private sector, government support fades away and subsequent delays in governmental reimbursement of provided services severely undermines the ability of contractors and investors to purchase equipment, laboratory materials, and medications, and even pay the personnel’s salaries. The government’s efforts to attract foreign investment to this area is also undercut by the same issue, as foreign investors expect some form of state guarantee before considering investment. Therefore, one of the major obstacles to attraction of private investment is the lack of guarantees regarding the steady support of the government .
The participants from public sector expressed strong tendency to establish public–private partnerships for provision of clinical and non-clinical support services, renovation and modernization of existing hospitals, and launching of new facilities. Meanwhile, the participants from the private sector expressed high interest in partnership for provision of support services and project financing.
In Australia, New Zealand, Canada, and most of the Europe, politicians are eager to employ the capabilities of private sector in provision of public services. In the UK, these partnerships are largely justified by the simple fact that the private sector is more efficient and cost-effective. In an international context, commentators have mostly encouraged the use of PPP because of their effects on accountability, service provision equality, and service availability . In a study conducted in southern Iran, senior managers of public hospitals were found to be most interested in delegation of hospital food and nutrition services to the private sector and least interested in employing this sector for nursing services. According to this study, these managers also had moderate tendency to delegate laboratory and radiological services to the private sector . The studies conducted by Young on outsourcing in the Australian healthcare sector  and by Tang Hsia et al. on Taiwanese hospitals  have also indicated the low inclination of managers to outsource clinical services.
In Iran, private sector participation in the form of PPP models can be realized in several areas. Given the chronic hospital bed shortage in Iran’s healthcare system and the old age and vulnerability of the existing hospital structures, the main priority of partnership with the private sector is the increase of hospital beds and renovation and reconstruction of existing hospitals. The statistics indicate that Iran’s healthcare system requires at least 100,000 additional hospital beds for it to reach a standard level. Creating such capacity is a huge endeavor that the government alone cannot afford to finance. But this objective can be achieved even in the short term with the help of nongovernmental sector, namely, the public institutions, foreign investment, and the domestic private sector. There are many examples of utilization of PPP model in different healthcare areas in different countries. For example, many countries have successfully used PPP models and private sector partnerships to increase the hospital bed capacity of their healthcare system (One example is the use of this approach to address hospital bed shortage in Brazil in 1999 ). In a survey conducted in Canada, 61% of participants believed that PPP is an appropriate approach for designing and constructing hospital and providing non-clinical services . In a study carried out in Sri Lanka, most participants stated that PPP is suitable mechanism for providing clinical and non-clinical services. More specifically, some of the surveyed experts believed that even the management and investment aspects of healthcare services should be delegated to the private sector; but there were also others who believed that only non-clinical and support services should be included in such partnerships . Other examples of the use of PPP to equip and modernize healthcare infrastructures can be found in France, Spain, Italy, and Portugal . New Zealand, the UK and India have also had successful experiences in partnership with private sector in providing hospital support services such as housekeeping and cleaning, food and nutrition, pharmacy and office staffing, facilities maintenance and transportation. Therefore, the capacities of Iranian private sector too can be utilized to improve the performance of support services .
Regarding the determinants of feasibility of PPP for hospital services, the results of the study showed that the participants viewed none of the six determinants of PPP as being in desirable condition. In other words, the participants believed that the conditions for the use of PPP model in Iranian hospital sector are far from favorable. Although the representatives of the public sector regarded the determinants classified in social-cultural, capacity creating, and procedural categories to be in better condition, the participants from the private sector believed that the policy-making, legal-regularity, and financial-capital factors are in better shape for implementation of PPP.
In a study on the feasibility of PPP in the Philippine’s healthcare system, the most important factors in implementation of PPP projects were found to be the existence of mutual trust, legal and policy framework, institutional framework, contract management, and a monitoring and supervision system. The presence of a legal framework that could properly protects the interests of both public and private parties is a prerequisite for any PPP program. The 2011 Economic Intelligence Unit’s report on the environment for public–private partnerships in Asia–Pacific introduced four indicators for a valid legal framework: (i) consistency and quality of PPP regulations, (ii) effective PPP selection and decision-making, (iii) fairness/openness of bids and contract changes, and (iv) dispute-resolution mechanisms .
The most important factors of implementation of PPP in China and Indonesia have been reported to be the presence of suitable legal framework. For the UK, this factor is the existence of a strong and capable consortium and for Taiwan it is the stability of economic conditions . In a study conducted by Spigars, it has been suggested that participation in PPP agreements would require specific legal and policy frameworks as well as proper legal and political capacity for launching and managing PPP projects in the government. In other words, the public sector must establish itself as a reliable partner with specific legal and regulatory boundaries . Banzon has also suggested that legal framework is a necessity for protecting the interests of both public and private sectors, and that policies should serve as a clinical guide on how to cooperate and participate and ensure that there is a sufficient incentive for private investors .
Successful implementation of PPP projects and mutual trust between public and private partners requires a culture of honesty, transparency and open communication. To achieve this, the government must create a business environment that would signify its readiness to engage with the private sector and investors through and within the framework provided by national laws and regulations. Proper adjustment of loan rates, providing adequate capital guarantee, directing more facilities toward productive sectors, and reducing transaction and financing costs are known to be among the most effective ways of attracting private investment. For an investor to reach the point of considering investment in a project, one should be fairly confident about the profitability of the activity, preservation of business ownership, and safety of his/her capital. Also, investors tend to thoroughly examine the profit and loss prospects of all available projects, both long-term and short-term, before committing any capital and direct their resources to the activities that yield the highest returns throughout their lifetime. From this perspective, macroeconomic factors also affect the type of investment, in the sense that, when there is a positive economic outlook, which represents capital security and financial stability, investors tend to direct more capital towards long-term physical investments, but in the absence of such environment, they tend to invest in service, trading, and speculative activities. At the same time economic status of the country the same as unsustainability of the investments, varied and fluctuated rate of currency and the high risk rate of investment along with the political economic sanctions imposed on the country can all intensify the problems of attracting private partnership. The government is recommended to have a long term plan for moderating the risk of each of these conditions.