1. Political issues
Changing managers in medical sciences universities is commonplace in Iran health system that affects the managers' view of the relationship with the NGOs. “The other problem is that changing the manager regularly [at the University of Medical Sciences] makes collaborations less and that's a lot” (p21).
The effects of political issues on deployment of NGO varied in different presidential courses of Iran. This has affected the expansion or decrease of NGOs participation in various fields, including healthcare, which analyzed in the work of Aghababa et al. . “a manager welcomes a donor, but tomorrow, another university manager fires the same donor. This happens a lot and makes the donor confused and uncertain” (P7, P20, P17).
The top-down view of the public sector towards NGOs has led to grammatical behaviors of public employees with NGOs, which has led to the discontent of NGOs and their diminished engagement with government areas “Sometimes when we [NGOs] had difficulty, we request the help of the University of Medical Sciences. But we were worried about their collusion” (p28).
The lack of public sector Supervision of NGOs in the health sector causes some NGOs to fail to comply with the guidelines. "Government must monitoring of semen performance and their activities" (p16).
During the interviews, some participants stated that in addition to political abuses, the government is also abusing NGOs. “They want us to support the political work of government agencies, but we do not engage ourselves” (p21).
NGOs should be able to play their role as a social capital in different fields and based on legal conditions and social regulations . Studies have emphasized on lack of certain rules and supervisions based on the founded law [8, 13, 14]. “tax exemption should also include healthcare NGOs. Getting loans by a donor has its own challenges. It means that the government is unable to provide some facilities in order to give us some loans” (P3, P9, P13, P16, P17).
2. Performance issues
The NGOs Board of Trustee includes a number of people who sometimes do not share a common view of how to pursue a path to accomplish activities and achieve the goals. "Unfortunately, teamwork is difficult ... One of the problems in NGOs is the difference in taste causing them not to perform or to move elsewhere” (p27).
Another challenge is lack of a comprehensive system among NGOs and governmental organizations which leads to injustice for receiving services . “An adroit person receives services from several sources, but another person who is unable in this regard will be deprived of services, and parallel processes intensify this problem” (P3, P5, P11, P12). “for receiving facilities from the governmental sector, there is a long process … if I [manager of NGOs] want to get help from someone in the field of healthcare, no one is responsible and I should refer and have a long talk from early morning each time” (P12, P11, P1, P18). This challenge is also referred to in a study by NHA  . This challenge is also referred to in Delislem et al.’s study .
Another problem which is highlighted by Lencucha is allocation of financial resources to healthcare system . These organizations have been converted to an auxiliary lever for aggregation of income [14, 15]. “They say that NGOs [healthcare NGOs] should enter economics in a legal framework, but it is a big challenge for us” (P1, P11, P12).
3. Cultural issues
Lack of cultural infra-structures with the aim of institutionalizing NGOs is another problem leading to weak performance of NGOs, which is also referred to in Musa’s study . “Collaboration should be cultural and educational” (P6, P18).
Another case mentioned in this section is the lack of recognition and culture for doing team work in the country. “In teamwork, we need to cultivate teamwork culture first, especially when it comes to health” (p19).
Attitudes in healthcare governmental sector should be modified, so that this sector should consider non-governmental sector as a collaborator in reaching developmental goals, not a competitor [20, 21]. “our main challenge [healthcare NGOs] is that they think we work internationally and work for making money and they do not cooperate with us” (P1, P4, P11). Another challenge is lack of people’s awareness from charity organizations which causes some challenges for these organizations in Iran. “In Iran, what is referred to as NGO is not inferred similarly by all the people” (p25).
4. Management issues
A challenge which is mostly stated with regard to management issues is weak support of governmental healthcare managers from NGOs. It is also referred to in the study of Anbazhagan and another study by Tucktuck [3, 5]. “The manager should believe in NGOs … a reason for detachment of NGOs is lack of governmental supports” (P 2, P5, P7, P11, P18). Another challenge, which is referred to in the study of Abdallah is the need for support from using collective capacities . Managers of NGOs need governmental supports for progress and fulfillment of their goals. These supports are not only limited to financial supports; providing appropriate infra-structures for foundation of NGOs, facilitating foundation of NGOs, educating the founders of these organizations, accurate and correct supervision of science with the aim of helping NGOs, trusting NGOs and introducing NGOs to the society are some other examples . “The manager has to believe that the benefactors can help ... extend their hand to them” (p18).
Lack of scientific management can be considered as a main cause of inefficiency in charity organizations . “manager should be trustful, known, and honest; so that we do not think of deceiving him/her [healthcare NGOs and the donor] in order to take money and spend it in another field” (P 1, P5, P6, P9).
5. Communication issues
Using media communications is the best way for interaction of NGOs who support patients with direct users in civil society . One of the stated challenges in this group is lack of regular and systematic communications of governmental sector with healthcare NGOs which is also referred to in the study of Delisle . “There is no regular communication with NGOs and the main problem is informing the hospitals about us” (P12, P11, P18).
Furthermore, another challenges, is unspecific number of NGOs and their fields of activities in healthcare system for creation of appropriate communication. Lack of active and appropriate network communication between NGOs causes a lot of challenges in their collaboration with healthcare governmental sector . “communication should be made between NGOs to provide guidelines and update their information” (p14).