What are the challenges and barriers for the entrepreneurship ecosystem in the Iranian health system?: A qualitative research

Abstract

BACKGROUND:

In the era of globalization, sustainable development is imperative for health and well-being of fellow citizens. With the available human resources and infrastructure, the Iranian heath system should provide a tremendous scope to contribute to the nation’s health economy. We need to identify and rectify the flows of our health economy. The thrust of this paper was to discover the challenges and barriers of achieving an entrepreneurial ecosystem in Iran’s health sector.

MATERIALS AND METHODS:

The study objectives and qualitative method allowed to conduct focus group interviews with 16 entrepreneurs, policy makers, operational executive directors, and researchers affiliated to public and private health sectors. Data were computer-analyzed using Max QDA 2020 software, yielding 4 categories, 10 subcategories, and 60 conceptual codes (challenges) revolving around 6 dimensions of Eisenberg’s entrepreneurship ecosystem (financing, politics, human capital, culture, market, infrastructure, and support). The validity and reliability of the results were evaluated and confirmed by matching the homogeneity of the findings.

RESULTS:

The participants enumerated 60 challenges in 4 major fields including policies, structural-organizational processes, implementers’ characteristics, and prevailing context and conditions based on Eisenberg’s ecosystem dimensions. The challenges are listed in order of importance as follows: the weaknesses in infrastructure and support systems, sociocultural elements, human capital, market, financing, and current health policies.

CONCLUSION:

Sixty barriers and challenges are found and listed in order of frequency and importance and categorized in six Eisenberg’s dimensions of ecosystem. Weaknesses in infrastructures, support system, and sociocultural elements are the most important barriers toward development.

Introduction

Entrepreneurship as creative destruction is the engine of economic and cultural development.[1] In risky situations, entrepreneurs create value by discovering opportunities and using resources to create productivity, wealth, welfare, and employment.[2] Creating a healthy ecosystem of entrepreneurship is a powerful mechanism for development.[3] Creating a healthy life and promoting well-being for everyone at all ages is the most important goal of sustainable development.[4] To achieve health for all, sustainable development, security, well-being, peace, education, and training of productive efficient work force are necessary.[4,5,6,7,8] The development of entrepreneurship requires the modification of a network of different elements, which Eisenberg (2011) calls it “the entrepreneurship ecosystem”, which consists of six dimensions: politics, culture, market, financing, human capital, and finally support and infrastructure.[9,10]

Considering complexities of the health system and the necessity of being up-to-date with every day changing health technology at a high speed, it is necessary to recognize the challenges and barriers (C and B) toward obtaining health for all.[11,12,13,14] Several studies show the impact of entrepreneurship in solving the major challenges of societies, including poverty, injustice, environmental hazards, and climate change. New services, expensive technologies, population aging, and cultural diversity have affected the conditions of providing healthcare services. This variety and multiplicity of activities has shown countless neglected opportunities and challenges.[6,8,15,16]

Now, in the field of health, we are sometimes dependent on importing essential and vital needs, leading to social health issues.[17,18,19,20] The research of global entrepreneurship observatory shows that 30% of the difference in the growth rate of gross domestic product is due to the difference in the level of entrepreneurial activities of the countries.[2] Iran is facing great challenges in economy. The progressive increase in the unemployment rate, especially in young educated individuals, the inflation rate, the subsidized nature of the country, low productivity, and low participation of the private sector are the most important challenges of the Iranian economy, the negative effects of which are clearly visible in the health sector.[2,21] Studies show that economic growth is a necessary condition for achieving a better quality of life and security. Expanding entrepreneurial companies are a solution to achieve various industrial technologies and economic development.[22]

Although international studies related to entrepreneurship have a long history,[8] Iranian entrepreneurship studies have been less than 25 years old, but we can see the increasing trend in recent years[23]; but these studies have not been holistic to convince entrepreneurship policy makers to take practical actions for the development of this ecosystem.[24]

It is difficult to predict the behavior of health systems. Epidemic diseases, high cost, advanced and ever-changing technologies, and consumerism nature of the health survives along with economic sanctions are among the most important challenges of our health system.[12,25] We should focus on entrepreneurship policies to develop various health-related technologies on both biomedical fields and high-quality survives with special attention to health tourism.[26] Entrepreneurial policies must be well studied, well designed, and long-lasting; therefore, they need to be the focus of our scientists and researchers to supply reliable data, information, and knowledge for our policy makers.[27]

In the literature review, no study was found to focus on the C and B of the entrepreneurial ecosystem of Iran’s health sector[28] However, Table 1 shows some of the most important researches conducted in this field as follows:

Table 1.

An overview of studies in this field

n		Year		Researcher (s)		Subject of research		Findings/conclusions		Ref. n
1		2023		Karimi et al.		Considers financial and economic, human capital, and market infrastructure as essential for the development of the entrepreneurial ecosystem of the province.		Divides the challenges into three categories: economic, organizational, and behavioral It concludes that the organizational structure and the opposition of entrepreneurial behaviors of the official authorities are the main obstacles.		[3]
1		2022		Kulkov et al.		Study on the challenges of entrepreneurship related to health technologies		Counted three levels of macro, meso, and micro for these challenges		[6]
2		2021		Farajzadehet et al.		Determining the effective factors on developing entrepreneurial managers in the Iranian health system		Organizational entrepreneurship of health care organizations in the country		[28]
4		2021		Naghavi Alhosseini et al.		Investigated the barriers and capacities of the country’s universities of medical sciences in the development of entrepreneurship		Considers educational and informational, cultural, social, financial, and structural and infrastructural barriers to hinder the development of entrepreneurship.		[30]
5		2019		Ferdowsi & Molavi Taleghani		Factors affecting entrepreneurship in Isfahan University of Medical Sciences		Organizational entrepreneurship of health care organizations in the country		[31]
6		2012		Dehghan et al		Factors affecting innovation and organizational entrepreneurship in the medical sciences universities		Structural, behavioral, and peripheral factors are the most important, which affect innovation and organizational entrepreneurship at medical universities.		[32]
7		2021		Golalizadeh et al.		Identified the challenges of financing knowledge-based companies in Iran		The challenges of the government’s financing policies, licensing policies, importing technology instead of starting up, and the lack of a suitable system for demanding technological entrepreneurship They mentioned supporting research and development as the most important challenges		[33]
8		2023		Norouzzadeh et al.		Examined the effective factors and identified obstacles and challenges in health tourism as one of the examples of entrepreneurship in the health sector		The tariffs for medical services, the suitability of the entrepreneurial environment, and specialized human resources and expressed the appropriateness of government policies.		[34]
9		2020		Kahrizi et al.		Identified the obstacles to the development of medical tourism entrepreneurship		Emphasize the weakness of the health information system, the weakness of supervision, process problems, and a weak competitive position as the most important obstacles.		[35]

The findings of international studies on the health entrepreneurship ecosystem suggest the necessity of regular and/or periodic studies to detect ever-changing challenges of the entrepreneurship ecosystem in our country. The different health systems and different markets of this industry in Iran as compared to other countries have made imitative entrepreneurship policies ineffective in Iran’s health sector; therefore, it is necessary to analyze the challenges of entrepreneurship in the field of health from the perspective of all actors in Iran.

Materials and Methods

Study design and setting

This research is an applied qualitative study using in-depth semistructured interviews with the main actors of the health sector’s in the entrepreneurship ecosystem according to Eisenberg’s model. It is done by in-depth interviews using the framework analysis method and MAX QDA 2020. The framework analysis is a new, flexible, regular, hierarchical method with specific steps for the analysis of qualitative data with a large volume; therefore, it is of special interest in the qualitative researches of the health sector.

The main steps of framework analysis according to Gal et al.[29] in a seven-step model include the following: 1. transcription and familiarization with the data by reading the implemented texts several times; 2. identifying and extracting primary codes and identification of themes; 3. placing codes in related themes; 4. developing an efficient analytical framework; 5. applying the framework; 6. drawing the data in the framework matrix; and 7. analyzing and synthesizing the data through their interpretation. In the analysis and evaluation of the findings, the criteria of verifiability, validity, transferability, trust, and stability were used. In order to increase the reliability and acceptability of the findings, the research was conducted as a team with the participation of several researchers with allocation of enough time for the interviews.

The researcher has seriously considered the subject as a mental concern throughout the entire study and in selecting and employing experienced and specialized participants in different aspects of the ecosystem. Iranian health entrepreneurship made maximum efforts in identifying the real C and B of the entrepreneurial ecosystem of the health sector of Iran.

In order to increase the reliability and stability of the study, some results were provided to the interviewees and their feedback was received; the judgements of the supervisors were used in the analysis of the interviews for coding and classification. The verifiability and transferability of the findings are also strengthened by the use of appropriate samples, accurate and technical description of the data, and simultaneous presentation of the results to small populations of entrepreneurs and feedback.

Study participants and sampling

The study community includes 16 experts in Iran’s health entrepreneurship ecosystem. In order to collect maximum diversity of data, selection of samples was done from the most experienced members of Iranian health entrepreneurs (medicine, medical equipment, services), policy makers, and also university professors with at least 5 years of experiences.

A pilot study is done for two interviewees to adjust our explanations to interviewees, interview duration, and the guide of interview [Table 2]. After obtaining informed consent from the selected interviewee and setting a suitable time, a 20 min explanation of the project and the perceived C and B of the researchers and the six dimensions of Eisenberg’s entrepreneurial ecosystem was done and then in-depth qualitative interviews were conducted [according to Table 2] and recorded. After conducting 16 qualitative interviews, the comprehensiveness of the information and saturation of the data was understood; therefore, study was forwarded next steps.

Table 2.

Guidance of semistructured interview

1. What is your view on the current state of the Iranian health sector’s entrepreneurial ecosystem? Do you consider the situation desirable and on the path of development?

2. What challenges, problems, and deficiencies do you think are on the path to the development of the Iranian health sector’s entrepreneurial ecosystem in the dimension of policies?

3. What is the most important challenge and obstacles to development in the market dimension?

4. In the context of infrastructure and entrepreneurial support in the health sector, what are the most important problems and challenges from your point of view?

5. In terms of financing, what do you know about the most important problems and obstacles of this ecosystem?

6. What is your view on the cultural challenges of Iran’s health entrepreneurship ecosystem?

7. What challenges and obstacles do you think are in the dimension of human capital for the development of the entrepreneurial ecosystem of the health sector of Iran?

8. Thank you for your valuable participation. Do you have any other opinion and suggestion about the problems and challenges of the entrepreneurial ecosystem of the health sector of the country?

Data analysis

Qualitative analysis is done by MAX QDA 2020.

Ethical consideration

The ethics code is obtained from Iran University of Medical Sciences (IUMS), with informed consent from the interviewees and permission to record interviews, keeping the records confidential and the right of interviewees to cancel and quit the interview at any time during the study.

Results

Descriptive findings are shown in Table 3 as below:

Table 3.

Descriptive findings

Criteria		Findings
The number of participants		16
Average age		55 years
Mean of professional experience		26 years
Field of activity including diagnostic and therapeutic services or health related technology		40% in the public health sector 27% in the private health sector 33% simultaneously in public and private
Level of activity		20% current or former macro policymakers with entrepreneurship activity. 26.5% executive and operational managers of the health sector 33.5% private sector entrepreneurs
Time of the interviews		Total time of interviews: 25 h Average time of each participant: 95 min

The selection of the interviewees was done according to their experiences in different fields purposefully so that the most variable experienced interviewees are selected.

Qualitative analytical findings

We extracted initially 312 codes, which expressed the C and B. After purification and classification in numerous meetings with the research team, we finally came up to 60 main codes (challenges), which is classified into four main categories and ten subcategories and six ecosystem dimensions. It should be noted that the coding was done by two researchers, and the agreement rate was 88%.

The interviewees were asked to cover their point of view in all six dimensions of Eisenberg’s entrepreneurial ecosystem (financing, human capital, culture, politics, market, and infrastructure and support). The challenges are organized into four main categories: 1. The policies, 2. Characteristics of implementers, 3. Context and conditions, and 4. Structural-organizational process. These four categories are subdivided with attention to the ecological dimension of each challenge as follows:

1. The policies:

   1. Existing bad policies that are harmful to the health entrepreneurship ecosystem.

   2. Policy gaps that the country’s policymakers need to address and formulate in future.

   Challenges related to the policies consist ten items as seen in Table 4. The most important challenges are the policy flaws and gaps, followed by harmful and damaging policies. In terms of the entrepreneurial ecosystem, policy gaps for infrastructure and support, followed by human capital and financing, are the most concentrated areas of defect. Furthermore, policy gaps related to policy audit including unfair rejection of technological projects, buying services for illness instead of health per capita, lack of a powerful system to direct and support technological entrepreneurship, and lack of an evidence base information center to supply policy makers and entrepreneurs are noted by the participants. Conflicts of interest within the health managers, policy makers, and entrepreneurs are also identified. Lack of strong governmental support for the research and developmental centers, think tanks groups, startups, and high-tech companies are elaborated; all these policies need a serious fight against corruptions to be effective.

2. Challenges related to the characteristics of implementers that are presented separately in four subcategories: 1 Government and the country’s public system, 2 Entrepreneurs, 3 Policy makers, and 4 Officials and executive directors [Table 5].

   The most important challenges for the health entrepreneurs in the order of frequency and impact are the government and public services, followed by incapable policymakers, corrupted or weak executive or operational managers, and finally the weak or unexperienced entrepreneurs. The most important C and B in Iran’s entrepreneurship ecosystem in the order of frequency and impact are unprepared culture, weak human capital, unclear market, and insufficient infrastructure and support.

3. Challenges related to the context and conditions, which are presented separately in two subcategories [Table 6]:

   1. general challenges of the country and

   2. specific challenges of the health sector

   The most frequent C and B are focused on the limited and unclear market, weak human capital, insufficient and unfair financing, unprepared culture, and defects in polices.

   Important challenges related to the context and general conditions of the country include decline of moral values in the new generation, deficient funding and governmental support, competition with foreign companies, monopolization in the market, a high inflation rate in the country, structure of the economy that formulates brokering and weakens technology, and migration of entrepreneurs, scientists, elites, and even expert workers. Furthermore, the incompatibility of working conditions with the capabilities and expectations of elites, the inappropriateness of customs financial, and banking policies with sanctions conditions are our challenges.

   Furthermore, a poor understanding of the market by policy makers and its various elements and complexities of the health services, technology, and market is a complaint of entrepreneurs. Other challenges include failure to use other specialties to better understand the mutual rights of suppliers, receivers, and intermediaries in the market such as insurance.

4. Challenges related to structural-organizational process [Table 7] with two subcategories of general C and B of the country and specific challenges of the health sector with 21 challenges

Table 4.

Challenges and barriers with regard to the dimensions of the ecosystem in the field of policies

Main category		Sub category		Challenges		Ecosystem Dimension
Issues related to the policies		Harmful, bad, and damaging policy		1. The disproportionation of banks’ financing policies with specific entrepreneurial requirements and conditions		Financing and capital
				2.Extremism and/or restrictions and/or sophisticated processes to get licenses for the business of technology entrepreneurs		Infrastructure and support
				3.Guidance of specialized human resources in the field of health toward providing disease services instead of health services		human capital
				4.The priority and dominance of policies are to import products rather than support domestic product and support the development of domestic technologies		politics
		Deficiency or policy gap		1. Lack of an appropriate auditing system for the acceptance/rejection process of innovative entrepreneurial projects by official organizations		Infrastructure and support
				2.Lack of insurance policy in support of buying health services, prevention and rehabilitation instead of disease services		Infrastructure and support
				3.Lack of proper policy and responsible systems to mandate and monitor the officials to be sensitive and reactive to the needs of health entrepreneurs and development of technology		human capital
				4.Evidence-based policy deficits based on actual and appropriate studies for health needs and requirements		politics
				5.Deficiencies of policies to eliminate and control conflicts of interest of senior health managers and fighting against corruptions		politics
				6.Lack of policies supporting research and development and think tanks		politics

Table 5.

Challenges and barriers with respect to the dimensions of the ecosystem

Main category		Sub category		Challenges		Ecosystem Dimension
Issues related to the characteristics of implementers		The government and the country’s public opinion		1. Lack of practical commitment by community leaders to sustainable development dependent on productive technological entrepreneurship in the country		Cultures
				2.Neglecting social honor and respect to the leading entrepreneurs		Cultures
				3.Inadequate ability of universities to train expert human resources for the development of technology with entrepreneur mentality		human capital
				4.Defects in educational and educational provisions appropriate and specific to the culture and ecosystem of entrepreneurship in Iran		human capital
				5.Disappointment and frustration in society of health experts and health managers in general and especially for the health technology entrepreneurs in specific		Cultures
				6.The drawbacks of public culture and attention to appearances rather than values		Cultures
				7.Development of a culture of consumption with dependency to the parents in newer generations		Cultures
				8.Lack of trust to the domestic products and goods		Cultures
				9.The ingrained cultural weakness of destructive competition and the overwhelming jealousy toward progressive movements		Cultures
		Policymakers		1.Discounting the great potential of health entrepreneurship opportunities in solving social and health problems		Market
				2.Disregard for the necessity of supporting private entrepreneurs to develop a sustainable ecosystem		Infrastructure and support
				3.Health managers tend to consume the latest imported technology rather than supporting the domestic productions to be upgraded		Infrastructure and support
		Entrepreneur		1.Lack of concentration of entrepreneurs in a specialized area which might be due to the sense of uncertainty		human capital
		Officials and executive directors		1.lack of awareness of the authorities to the evolving knowledge, methods, standards, and new technologies		Market
				2.Weakening of patriotism culture and the lack of commitment of the authorities to preserve and grow the country’s capital		Cultures
				3.Inability to gain the trust of entrepreneurs by officials and managers		Cultures

Table 6.

Challenges and barriers with respect to the dimensions of the ecosystem in the field of context and conditions

Main category		Sub category		Challenges		Ecosystem Dimension
Challenges related to context and conditions		General of the country		1) The decline of moral values in the new generations of graduates		Cultures
				2) Insufficient governmental funding in support of entrepreneurship		Financing and capital
				3) Hardness of domestic entrepreneur competition with international companies		market
				4. Exclusivity of semigovernmental and international companies in the market		market
				5) High inflation rate in the country and the momentary reduction of resources provided by entrepreneurship		Financing and capital
				6) Economic structure of consolidated speculation and brokering instead of technology and production		Financing and capital
				7) The migration of entrepreneurs, elites, and even technicians to abroad		human capital
				8) Disproportionality of working conditions with the ability, capability, and expectations of the elite entrepreneur		human capital
				9) The disproportionality of customs, tax, and banking policies with sanction conditions		policy
		Specific to Health system		1.The failure of policymakers to properly understand and authorities about the market and its various elements and dimensions		market
				2.Complexity multidimensionality, vitality, specialty of health market, and technology		market
				3.Inadequate success in exploiting other disciplines and specialties in the health sector		human capital
				4.Bilateral defects in understanding the mutual rights between supplier and recipient of service and insurers		Cultures

Table 7.

Challenges and barriers with respect to the dimensions of ecosystem in the field of structural-organizational-process problems

Main category		Sub category		Challenges		Ecosystem Dimension
Challenges related to structural-organizational-process problems		General of the country		Malfunctions in responsible areas for the transparency and quality of the information transfer process		Infrastructure and support
				2.Malfunction of licensing organizations (sluggishness, bureaucracy, and corruption)		Infrastructure and support
				3.Government failure to distribute government assets wisely (for example: importing goods instead of promoting national technology and supporting entrepreneurs. Government pays in advance in dollar for expensive import and is always creditor while tries to buy mush cheaper from domestic companies in rials and is always a major debtor to Iranian companies)		Infrastructure and support
				4.Unfair distribution of support to public companies rather than private entrepreneurship		Infrastructure and support
				5.Operational problems of electronics and digitalization of organizational processes with insufficient IT infrastructures leading to more delay and unresponsiveness		Infrastructure and support
				6.Design of customs facilities and cargo facilities solely for petroleum goods		Infrastructure and support
				7.Failure to choose managers and health officials from entrepreneurs and productive persons		human capital
				8.Noncomprehensive and nonscientific approach in developmental plans		Cultures
				9.Unbalanced accumulation of national resources and supports in the capital and deprivation of provinces		Infrastructure and support
		Specific to health system		1.The unbalanced power of governmental and semigovernmental corporations (apparently private companies affiliated with the authorities)		Infrastructure and support
				2.Concerns over corruption in health-related markets		market
				3.The poor performance of responsible organizations for continuous evaluation of health market and notifications to economic activists of health sector		market
				4.Inadequate power of health services for tariff determination and fair monitoring systems		market
				5.A defect in the obligation of insurers to pay properly and at the time of service charge		market
				6.The inadequacy of amount, inappropriate time, interest and process in which financial support is delivered with variable process for each bank especially for startups and the so called knowledge-based entrepreneurship		Financing and capital
				7.The direction of bank’s policies toward importing and purchasing rather than domestic production because of lower risk and fast circulation of money		Financing and capital
				8.Incomprehensive approach for designing and creating new specialized fields in health		human capital
				9.Defects of specialized training programs for entrepreneurs and professional members of his team		human capital
				10.Spending health sector resources on rent and bribery rather than support for development of domestic technology		Financing and capital
				11.Noncompliance with ethics and creating inductive demands in health sector		Cultures
				12.Governmentality of health sector services and policies (Great Government)		Polities

Table 8 shows some of the qualitative pieces of evidence and quotes of the participants in the field of C and B.

Table 8.

Qualitative evidence – quoting contributors

n of Note		Evidence		No. of participants
1		Policymakers and officials compete with the private sector when we say the health market, i.e., the health system. So why should not we want someone to stay in this market and help us with our tasks.		13
2		If the Ministry of Health officials says “leveling”! What does it mean? The simple operational meaning is: where we take our interests, you must not seek an interests! As long as our policy makers themselves have personal interests in various companies in the country, they will pass the law on the basis of their own personal interests. These “khosoolati (semi-governmental)” companies would not let the country grow.		10
3		Today, one of the most important obstacles of knowledge-based companies is the existence of “khosoolati (semigovernmental)” Very big vermin they are destroyers. This is all in the leader’s conversations. In fact, removing and erasing the environment from these is also one of the necessities that is neglected because some people benefit from it.		14
4		Public companies, when they get into trouble, get state support; on the other hand, they have a monopoly market and state backed capital. They go bankrupt no one gets upset. They say we should pay our salaries and then the problems will be compensated by the sales. What about private companies? Unsponsored they should be barely staying in the market in competition with the governments as they are.		15
5		In these six dimensions of the ecosystem that you said is currently the least problems is human power and capital, which unfortunately, now a major flood of migration is seen to abroad. So much gone we have so many of these 300 (out of 1000) people we lost recently going out. Even countries like Uzbekistan. I can’t believe that our people are looking to go to work in Uzbekistan!		12
6		We all know that the countries around us, including Turkey, the United Arab Emirates, Iraqi Kurdistan, Georgia, benefited from the whereabouts of human resources and wealth of Iran. Other European, Asian and American-Canadian countries also benefited from this colorful Blessings for many years		01
7		You’re gonna pay for a startup a year and a half later!? When they’ve emigrated. I’ll tell you the experience of a colleague. He said we formed a team, we wrote a proposal, but they gave the money a year and a half later, half of the team migrated. What do I do with a splash team after a year and a half with that poor money? What good is it for me anymore? The government has taken a risk, supported it’s good but maybe he won’t get the result he expected he’s thrown his money away too. No that’s worth the money a year and a half ago, there’s no other team! That’s what happens a lot. At one time, even grants do not work for us. A year and a half ago, they asked to solve a problem when they wanted to work for their country, but they gave the loan a month ago. how much? Seventy million toman! At that time, with 70 Tomans, they could develop their technology, some of them gained experience and emigrated. This is the “drug after Sohrab’s death”. We have a golden time of a year or two after the student graduate, if the government doesn’t pay where they’re developing their ideas. It’s not much different now whether the government is spending the budget, but maybe at this time their plans have changed a lot		09

Discussion

This study is conducted to collect and analyze the most important C and B toward development of the health entrepreneurial ecosystem in Iran. The findings of the study show that the most challenges are concentrated in policy makers, followed by official executive managers, weakness of national strategic plans and/or the monitoring mechanisms, the banking system, financial policies, and the educational system. Furthermore, support, culture, human capital, market, financing, and general politics have been mentioned as our C and B. The most important C and B of the government category are Iran’s health features, tariffs, insurers, financing policies (not sustainable for technology entrepreneurship), induced demands, pseudomarkets, educational problems, and corruption in all steps of the process of the entrepreneurship ecosystem, especially market and finances.

Phillips and Frank et al.[36] reported that the organizational and behavioral structures are the main C and B. Although this study was much smaller and did not consider all dimensions of the ecosystem, its results are consistent with the corresponding part of the present study.

Another study, which investigated the C and B in health tourism, found the importance of medical service tariffs and the inappropriateness of policies and laws.[34] According to their participants, the semigovernmental companies play a negative role in the path of sustainable development due to unbalanced power and information rent. Our participants who were senior high-rank policy makers or managers also emphasized on theis C and B. Among the pieces of evidence stated in this context, the following examples can be mentioned as seen in Table 8: Note N 1, Note N 2, Note N 3, Note N4.

Iran’s health system is mainly governmental, despite several clauses in the general policies of the leadership notification for the system for necessity of privatization; it has not happened. This is actually our super challenge. The findings of this study have separately pointed to each of the challenges of corruptions, ignorance of the market, incorrect tariff setting and lack of supervision, lack of commitment, and failure to fulfill the main mission by the government and irresponsible nonscientific insurance companies, rent, and bribery. In fact, a combination of these challenges have hindered the sustainable development of the country, especially in the vital sector of health. C and B related to the context and conditions at the general level of the country seems to be specific to Iran’s ecosystem as mentioned in Note N5 and Note N6 [see Table 8].

Decline of moral values, high inflation rate, brokered economic structure, and incommensurability of customs policies with embargoes are detected in our study, but the challenges of low government budget, tough competition, and failure to meet the expectations of entrepreneurs are shown by Karimi et al.[3] and an open market for development of the entrepreneurship ecosystem.

Neglecting to honor leading entrepreneurs, lack of commitment to entrepreneurship among the elders of the country, social hopelessness, pricing on appearance instead of authenticity, consumerism instead of being productive, jealousy, unhealthy competitions, mistrust, and disloyalty to the national brand were mentioned as our cultural barriers. Hosseini evaluated the barriers and capacities of medical science universities for development of entrepreneurship from the point of view of educational experts. He concludes that education for accessing to information, understanding the culture of the society, financing strategy, and considering structural and infrastructural problems of our educational system are important challenges for the development of entrepreneurship in Iran.[13,30,31,32]

Other barriers shown in our study are nontransparency and resistance to release information necessary for entrepreneurs to develop technology, restrictions, and resistance for issuance of licenses, unfair distribution of government currency and support resources, unprepared mechanization and electronization of the government, the selection of weak top managers, problems with importing rules and regulations, and unfair taxes. Lack of a scientific, comprehensive, and far-sighted strategy leads to accumulation of resources and supports in the capital city of Tehran. Weakness of the health information system, weak supervision, process problems, and weak competitive position are shown as barriers toward health tourism.[35]

Insufficient evidence-based information for developing macro and micro policies is shown in our study. Other studies have reported similar results.[6,37,38]

Policy maker’s poor understanding of the market and health products, lack of understanding of the mutual rights of suppliers, receivers and intermediaries in the provision of services (insurance), and the inability of the health sector to benefit from the capabilities of private section are seen.

Harmful, bad, and damaging policies are clearly visible in the health sector. Since 90s, the government and politicians moved toward employment creation but less focused on productive technology entrepreneurship.[37,38] Although limited resources were allocated for the vice president for science, technology, and knowledge-based economy, such as the resources of the “Foreign exchange development fund”, “the innovation and prosperity fund”, and some minor funds for knowledge-based companies, our participants mentioned that these “weak capitals” are not helpful for developing entrepreneurship and are mostly wasting the country’s limited resources. Actually, it is mainly used as the cost of training for those who intend to gain experience and emigrate. Note N07

Other studies have shown that the main C and B in the growth and development of companies and entrepreneurs are the limitations of financial resources, weak insurance supports, licensing policies, introducing finished technology instead of launching technology in our companies, and lack of infrastructure and intellectual atmosphere to build it up as demanding entrepreneurship with backbone of research and development sections.[33]

In summary, the financing of the country is not entrepreneurship-motivated. It is more a palliative for entrepreneurship. Furthermore, theses financial supports have many problems and in all dimensions including the amount and volume of support, laws and requirements, methods, related administrative and organizational processes to gain the fund, long process of receiving the fund, method of collection, performance of brokers, and banks to pay the funds. The healthiness of the process has many C and B; it is not coordinated and compatible with other components of the ecosystem, and not only it does not support entrepreneurship but also it is contrary to the alphabet of entrepreneurship with technology development. This type of financial support destroys the country’s limited resources because it is not a strong capital and to act as a driver of the country’s economy.

In the fifth place, the C and B related to the characteristics of implementers and the challenges related to the officials and managers as ecological implementers is described. The most important challenge of this aspect is the neglect of the importance and values of entrepreneurs in preventing social issues and solving challenges in the area under responsibility. The function of entrepreneurship in solving social superchallenges has been emphasized in international studies, including the study of Ricciardi et al.,[8] which has shown that through entrepreneurship, major social issues such as poverty, injustice, and environmental hazards can be solved and prevented. Another study was conducted by Muldoon et al., which shows the function of entrepreneurship in achieving the sustainable development goals (SDGs)[39] and confirms the importance of policy makers and officials’ understanding of the values and functions of entrepreneurs in advancing goals and missions of the governments, not to consider them as an imposed and unnecessary task of their missions and responsibilities.[4] Other challenges related to policymakers are neglecting the value and importance of private entrepreneurs and spending government resources to import technologies instead of trying to strengthen the national production capacities. He explained this problem in the discussion of nonimplementation of Article 44 of the Constitution and ignorance of the policies announced by the leadership.[40]

The challenges related to the officials also point to the lack of knowledge and awareness of new technologies and the lack of belonging to the homeland (patriotism) and the lack commitment to preserve the material and spiritual capital of the country as the main implementers of Iran’s entrepreneurial ecosystem. This shows the general weakness of the country. It deserves the dictatorship and the correct selection of expert, committed, pure, and effective managers in the country’s destiny. It should be noted that this challenge is clearly evident and understandable in real experiences in different areas of the country. C and B have been pointed out in various studies in the field of human resource management.[40] In the last rank and with the lowest priority are the challenges related to the category of entrepreneurs as ecosystem implementers, who, from the point of view of entrepreneurs and policy makers, have not focused on a specialized area due to their innovative and risk-taking personalities. They face delay and risk in achieving the results.

Based on the aforementioned findings, it can be concluded that the country’s health sector has less challenges in the field of entrepreneurs as the main implementers of the ecosystem.[41] To solve the C and B of the entrepreneurial ecosystem, the priority is to solve the structural-organizational process for the specific challenges of the health sector in the field of technological entrepreneurship.[42]

The intertexture, context, and general conditions of the country have more challenges than the specific intertexture of the health sector (nine challenges versus four challenges).

It should be mentioned that based on the opinion of the participants and experts, solving the challenges in this area requires long-term planning and culture building.

Limitations of this study are as follows: 1. Access to key entrepreneurs as main participants in getting a suitable number of participants and enough interview time is very difficult. 2. Since C and B are multifactorial and have a high interactions, to understand the impact of each problem on the ecosystem needs system dynamic study and analysis.

It is recommended to conduct a qualitative study on strategies to overcome the C and B in the development of the entrepreneurship ecosystem using the results of the present study. We should also have interventional studies to find the most effective strategies for improvement of the ecosystem.

Conclusion

The findings of the study show that there are serious and structural C and B in all aspects of the entrepreneurship ecosystem of Iran’s health system. It is necessary for policymakers to overcome the prevailing C and B toward health ecosystem development; we need to revise our health policies incorporating full social, political, economic, cultural, and educational support for the technological entrepreneurs.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

This study was supported by IUMS (Grant number and Ethical code (IR.IUMS.REC.1398.013)- (IUMS/SHMIS_1397_4_37_14141).