Vol 17 No 03  May-June 2020   112

Financial Burden of Prostate Cancer Screening: Changing Trends After Health Sector Reform in a 
Developing Country

Mohammad Reza Nowroozi, Erfan Amini*, Farhad Pishgar, Mohsen Ayati, Hassan Jamshidian, 
Seyed Majid Aghamiri

Uro-Oncology Research Center, Tehran University of Medical Sciences, Tehran, Iran.

* Correspondence: Assistant Professor of Urology, Department of Urology, Uro-Oncology Research Center, Tehran University of 
Medical Sciences. Tehran, Iran. 
Telephone: +98 21 6690 3063, Fax: +98 21 6690 3063, E-mail address: e-amini@sina.tums.ac.ir; amini.erfan@gmail.com.

Iranian health system has experienced several reforms in past decades, including establishment of primary health-care network as well as the family physician program and the social protection scheme in rural areas.(1) The new 
government, elected in June 2013, took health as the top priority and conducted health sector transformation plan 
(HSTP) on May 5, 2014, with the aims of improving health service quality in government hospitals, providing in-
surance to uninsured Iranians, and lowering out-of-pocket payments. Upon launch of the HSTP, it was welcomed 
both by patients and health care workers and public satisfaction rate increased to 75%. However, as the program 
progressed several obstacles emerged, mostly related to the financial burden of the plan, lack of health-related 
facilities and hospital beds, as well as overuse of services.(1,2)
Uninformed and unselected opportunistic prostate cancer screening has increased during the implementation of the 
HSTP. Prostate cancer does not seem to be a leading cause of death among Iranians and the mortality rate has been 
estimated to be 2.3 deaths per 100,000, far away from the reported rate in the United States.(3) However, an increas-
ing number of men with elevated serum prostate-specific antigen level are being screened for prostate cancer as 
a consequence of the significant reduction in out-of-pocket payments. Since the implementation of the HSTP, we 
have noted 30% increase in prostate biopsies in our institution, a referral center in the field of urologic oncology, 
resulting in substantial increase in the diagnosis of indolent prostate cancer. Prostate cancer overdiagnosis exposes 
men to the potential morbidities of unnecessary treatments, lowers quality of life, and imposes additional costs to 
the healthcare system.(4,5)
Prioritizing of the problems and the solutions is an inevitable part in the planning of health sector reforms. The 
absence of a well-organized health information system in Iran prevents the efficient assessment of health status 
in addition to impeaching development of national clinical guidelines. Preparing such guidelines as a part of the 
HSTP has the potential to overcome overdetection, overtreatment of diseases, and decreases the financial burdens 
of the plan. Economic burden of HSTP on the public budget has already raised concerns about the sustainability of 
the program. The government has invested vast sums in the healthcare system; however, government budget defi-
cits and the fragmented pooling of health insurance funds(6) have led to unpaid wages for up to six months among 
health workforces in some government hospitals. Strict monitoring of the reform process, health information sys-
tem improvement, developing national guidelines and precise prioritizing of the health challenges are crucial for 
the sustainability of the HSTP and implementing health reforms properly.  

REFERENCES
 1. Moradi-Lakeh M, Vosoogh-Moghaddam A. Health Sector Evolution Plan in Iran; Equity and Sustainability 

Concerns. Int J Health Policy Manag. 2015;4:637.
 2. Karami Matin B, Hajizadeh M, Najafi F, Homaie Rad E, Piroozi B, Rezaei S. The impact of health sector 

evolution plan on hospitalization and cesarean section rates in Iran: an interrupted time series analysis. 
International Journal for Quality in Health Care. 2018;30:75.

 3. Mousavi SM, Gouya MM, Ramazani R, Davanlou M, Hajsadeghi N, Seddighi Z. Cancer incidence and 
mortality in Iran. Ann Oncol. 2009;20:556.

 4. Heijnsdijk EA, Wever EM, Auvinen A, et al. Quality-of-life effects of prostate-specific antigen screening. 
N Engl J Med. 2012;367:595.

 5. Loeb S. Will Changes to Prostate Cancer Screening Guidelines Preserve Benefits and Reduce Harm? Eur 
Urol. 2016.

 6. Bazyar M, Rashidian A, Kane S, Vaez Mahdavi MR, Akbari Sari A, Doshmangir L. Policy Options 
to Reduce Fragmentation in the Pooling of Health Insurance Funds in Iran. Int J Health Policy Manag. 
2016;5:253.

LETTER

Urology Journal/Vol 17 No. 3/ May-June 2020/ pp. 325-325. [DOI: 10.22037/uj.v0i0.4738]