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

Iranian health system has experienced several reforms in past decades, including establishment of primary healthcare 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 insurance 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 increasing 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 deficits 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 system improvement, developing national guidelines and precise prioritizing of the health challenges are crucial for the sustainability of the HSTP and implementing health reforms properly.