Keywords

Introduction

Patients with cancer are prone to experiencing countless problems in all the personal, family, and social aspects of their life. In order to prevent the adverse effects of disease from setting in and to improve the patients’ quality of life as the main purpose of cancer treatment and care, a comprehensive system of both cancer care and palliative and supportive care needs to be established. According to a recent study by the World Health Organization, many countries do not have a cancer control plan that includes the prevention, early detection, treatment, and care of cancer; this study then reveals the urgent help required in these countries to reduce cancer-related mortality and provide long-term treatments and proper care to prevent pain and suffering in humans.

This chapter aims to introduce and present the status of both cancer care and palliative and supportive care in the Islamic Republic of Iran, that is, a country that has recently started devising plans for providing this type of care as well. Cancer is the third leading cause of death in Iran, and the increasing number of cancer patients in the country has turned this disease into a major challenge posed to the national health system. This chapter attempts to explain the current status of cancer in Iran, the present challenges of cancer care, the cultural factors associated with cancer care, the educational and academic challenges, the share and participation of the state and other organizations in cancer care and in providing palliative and supportive care.

The Current Status of Cancer Care in Iran

Iran is located in Southwest Asia, and, as a developing country, it is in an epidemiological transition from communicable to noncommunicable diseases, and is therefore faced with a doubled burden of diseases [1].

As a chronic disease, cancer is the second leading cause of death after cardiac diseases in western countries and in the USA [2], and the third leading cause of death after cardiac diseases and accidents in Iran [3]. According to the latest statistics, the annual incidence rate of cancer in Iran is about 107 per 100,000 people. Given the country’s population of nearly 75 million, more than 80,000 people get afflicted with cancer every year. Due to the increasing environmental pollutions and the growing elderly population, cancer is expected to be on the rising trend and to become a major health problem of Iran in the next decade [4]. As a result of the high incidence rate of cancer in Iran and the reducing age of affliction with this difficult and costly disease, some cancer specialists are now using the term “cancer tsunami” to illustrate the severity of the human and financial damages caused by this disease in the country [5]. At the present time, more than 30,000 people die of cancer in Iran every year [6]. The World Health Organization predicts that, by 2020 in Iran, the incidence of cancer will reach 85,653 cases and cancer mortality rates, too, will reach 62,897 cases. It is our hope that, with proper scientific planning for the prevention of the incidence of controllable and preventable cancers, these numbers will decline [7].

In 2009, of the total 74,067 registered cases of cancer, 41,160 (55.58 %) were men and 32,898 (44.41 %) were women. The gender ratio of cancer incidence was therefore 125 during this year which means that 100 female patients existed for every 125 male patients. In Iran, breast cancer still ranks first among women, with the peak age of incidence being around 50–55 years. The five most common cancers in women include breast, skin, colorectal, stomach, and esophagus cancer, in descending order of prevalence; and in men, they include skin, stomach, prostate, bladder, and colorectal cancer, in the same order. The five most common cancers in Iran irrespective of gender include skin, breast, stomach, colorectal, and bladder cancer (Table 20.1) [8].

Table 20.1 Ten most common cancers in Iran (2009)
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These statistics are somewhat similar to statistics provided for the various types of cancer in the USA and across the world. However, stomach and esophagus cancers are relatively more prevalent in Iran compared to the global statistics of common cancers. Stomach cancer is highly prevalent in northwestern Iran and esophagus cancer is more common in northeastern Iran, while both less prevalent in central Iran. For instance, the Age-Standardized Rate (ASR) of the incidence of stomach cancer in Ardebil province in northwestern Iran is 49.1 for men and 25.4 for women. Esophagus cancer is highly prevalent in Golestan province in northeastern Iran, which is attributed to habits such as drinking hot tea, not consuming fresh food, and drug use [1].

As the most common cancer among Iranian women, and given that it involves women in their reproductive ages and has a lower age distribution in Iran compared to other countries, breast cancer has always been a major concern for the national health authorities. With an incidence rate of 25 in 100,000 people and nearly 8000 new patients per year, this disease imposes a great degree of negative economic, social, and mental consequences on the individual, the society, and the health system [9]. According to a cancer registry report of 2009 in Iran, 7582 cases of breast cancer were diagnosed in Iranian women, with a peak incidence age of 50–55 years and an ASR of 28.25 in 100,000 women. According to the report data, about 49.4 % of the breast cancer population is in the age group of 50 and older, 31.2 % in the 40–49 age group, and 19.4 % are younger than 40 [8].

Although implementing breast cancer prevention and screening programs are highly efficient tools for the early diagnosis of this cancer, they have yet to be seriously adopted by women and advised by most physicians. Poverty, the lack of health insurance coverage and the absence of regular prevention and screening programs are barriers to the control of cancer. It appears that the poor awareness of women in Iran about the risk factors, symptoms and signs and benefits of screening programs and the functional deficiencies of health clinics in relation to cancer, in particular breast cancer, are due to the absence of prevention programs [10].

Cancer Care and Critical Clinical Issues

Problems of the health system of the Islamic Republic of Iran can be summarized in nine subgroups, some of which challenge the cancer care system and, consequently, the provision of palliative care. Some of them include equity in offering service providing systems (health costs, lack of insurance coverage), efficacy and quality (the absence of a system for evaluating the cost-effectiveness of services), structure (a centralized structure, lack of a defined status for the nongovernmental sector, ineffectiveness of the existing structure faced with new impositions such as cancer), health information system (non-registration of actions, lack of statistics on admitted cases, bed occupancy, etc.), service providing workforce (preference of physical resources over human resources, disproportionate workforce), funding resources, payment systems, and rules and regulations (law deficiencies and conflicting laws) [11].

According to experts of the field, much less attention is being paid to cancer in Iran than in advanced countries, as the public health care status and efforts for culture-building and informing the public have not been emphasized. Cancer registration is not carried out meticulously, and the oncology curriculum is still left unattended by the Ministry of Health and Medical Education, which is in charge of making policies on and executing medical education programs [12].

A number of challenges in the field of cancer care in Iran are discussed in the following section.

Cancer Registry

The prevention and reduction of cancer cases require cancer control programs to be implemented. A cancer registry system is considered a major component of cancer control programs. Iran’s Cancer Registry was approved in 1984 and published its first cancer registry report in 1986 with 18,435 cases of cancer. The second cancer registry report of 1996 was published in 1999 with 11,025 cases of cancer. This report had registered only 18 % of all the new cases of cancer. Until 2007, cancer registration was based only on pathology reports. However, due to the system’s failure to diagnose cancers that are diagnosed without biopsy, such as brain cancer, a population-based registration system was established across 20 universities of the country in 2008 to complement the pathology-based registration. The statistics rose to 74,067 cases of cancer in 2009. Tehran has qualities that make it perfect for being the center of cancer registry, for example, being home to 10 % of the country’s population, to diverse ethnic groups and also to various centers [13].

The National Cancer Registry of Iran covers the whole area and the entire population of the country. Cancer registry is administered centrally by the Ministry of Health and Medical Education. Collected cancer data are sent to the Cancer Office by the health deputies to be published in the form of national reports after thorough statistical analysis. Although the first comprehensive registry report was published in 2004, no such reports have yet been published in the book “Cancer incidence in five continents.” The registry is entirely funded through state budgets by the Ministry of Health. There are no independent registries or registrars at the provincial level; instead, data is collected by health deputies [14]. This 5-year program is intended to achieve the desired results in pilot provinces over the next 5 years, and then, if required and if the necessary infrastructures are in place, to be extended to the entire country [15].

Pain and Pain Management

Pain caused by cancer itself or the complications arising from its treatment procedures affect 50–90 % of the patients with cancer. Uncontrolled cancer pain sometimes pushes patients toward suicide [16]. Pain and its management comprise a crucial aspect of cancer care. Pain is a global phenomenon that affects quality of life in people across all cultures. Culture affects all the aspects of the experience of cancer in the patients, their family caregivers, and professional healthcare providers, including the perception, expression, and treatment of pain by the patient and their family. Cultural background has long been recognized as an influential factor in understanding the perception of and the reaction to pain. Findings of studies have shown that family culture, beliefs, and religion play a decisive role in the perception and management of pain by patients and their caregivers. All members of the multidisciplinary oncology team who provide care for the patient should be attentive to the patient’s cultural beliefs associated with his health and take advantage of them in their care [17].

There are different cultural and belief perspectives about pain. In some cultures where religion plays a strong role, pain is believed to have been granted by God, and it is a human obligation to tolerate pain; in these cultures, pain is an accepted and anticipated form of life; in other words, pain and disease are human fate and should be tolerated, or else result from the evil deeds of humans [17]. In Islam, pain and suffering is regarded as the patient’s atonement for sins [18]. That is why most people consider cancer similar to the tolerating of pain and suffering [19].

In a study conducted with the purpose of determining the relationship between attitude to pain relief and receiving analgesics in patients with cancer, most patients were of the attitude that analgesics are addictive, which might owe to their poor information. Yet, at the end stages of disease, the patient’s pain relief and comfort take priority. According to results, patients with the attitude that analgesics are addictive used significantly less amount of opioids than others. Patients with fewer false beliefs and attitudes about pain and the management of pain received sufficient analgesics and were thus able to effectively and adequately control their pain [20].

According to statistics provided by the International Narcotics Control Board (INCB) on the use of opioid analgesics, Iran ranked 115 in the world, 25 in Asia, and 15 in the region, therefore grouped among the low-consumption countries. Nevertheless, Iran is a rich country in terms of raw materials and manufacturing technology required for the production of opioid analgesics, and Mehrdarou, Exir, Shadarou, Daroupakhsh, and Tofighdaru companies produce drugs such as methadone, codeine, oral oxycodone, and morphine injection. The drug formulary used in Iran for opioid analgesics, in particular non-synthetic analgesics, complies in part with the World Health Organization’s approved list. These drugs are also so inexpensive that require almost no economic support system at all [21]. A report published in February 2013 assessing the method of opioid use in palliative care attributes the low consumption of these drugs to the lack of proper access to opioid drugs and also, in some cases, the negative attitudes of physicians, patients, and their families to opioid drugs [21].

In a study conducted by Mohagheghi et al. (2003) on 304 cancer patients, the patients’ most frequently used opioid drug included morphine injection, oral opium, and methadone (injectable and oral). These researchers also noted the inadequate variety of opioid drugs in Iran and the unfamiliarity of most physicians and almost all patients with the inadequate medical and administrative route for the prescription and preparation of the opioids. The available prescription drugs are also not used in a systematic fashion, and inappropriate use, including abuse, low or high dosage, improper administration route and sequence and carelessness about drug interferences, is widely witnessed. Standard instructions issued by university committees in partnership with the Ministry of Health might be helpful in resolving the current problems [22]. Stringent rules govern the use of opioids in Iran, and due to the absence of statistics on the level of opioid use in cancer patients, this data can only be accessed through a patient registration system in universities of medical sciences across different regions of the country. In Iran, the Food and Drug Department stationed in every university of medical sciences is responsible for providing the opioid drug demands of the medical centers within its area of coverage. The office of Controlled Drugs and Substances of each deputy is responsible for filing separate records for all patients demanding these drugs. Patients who have been using opioids for over a year should be examined by a medical committee, and should be able to refill their prescriptions after their disease and their opioid demands are confirmed once more. After this step, patients can refill their prescriptions for one more month [21].

Cost of Cancer Care

All the health systems across the world are faced with the rising costs of health care threatening high quality care. Health care costs have also sharply risen during the past few years in Iran , posing challenges to the state, insurance companies, and patients. In Iran, there are three sources for budgeting health care, including public state funding, health insurance payments, and individuals’ out-of-pocket expenses [23]. Although the country’s health budget has been constantly increasing in recent years, and thought it has now three times its previous amount, out-of-pocket expenditure on health remains as high as 55 % [24].

The treatment of cancer is a vital medical obligation. Treatments performed on cancer patients are often invasive and severe and require large expenditure of resources. Treating cancer is a costly affair that not only threatens life and welfare, but also puts the patient’s financial security at risk [25]. In Iran, patients with cancer have to travel long distances to receive proper treatment, which increases the financial burden imposed on them or their families. The demand for the treatment of cancer and its associated financial pressures can be a strong source of stress for the patients and their families, particularly in the case of low-income patients. The early estimation of the costs of care for cancer patients is an important component of the development of national cancer policies and programs. Cancer costs of patients are at their peak during the first 6 months after diagnosis and the last 12 months before death, and they significantly reduce between these two stages [25].

A major challenge posed to the treatment of patients with cancer is the discriminate distribution of specialists across the country, which somehow increases costs incurred by patients. For instance, it appears that the dense concentration of more experienced specialists and stronger diagnostic services in Tehran, the country’s capital city, allows the patients to be diagnosed with fewer doctor’s visits and diagnostic services. The high costs of treatments such as chemotherapy and surgeries incurred by patients in Tehran are attributed to the stronger, more active presence of the private sector in Tehran, while in other cities, patients usually use the cheaper services of the public sector [25].

Adopting new policies to cover the costs incurred by cancer patients, particularly by insurance companies, receiving funding through institutions such as banks or charities, the indiscriminate distribution of specialized cancer centers or providing temporary accommodation to patients traveling from other cities can reduce the financial burdens imposed on cancer patients and help them in their management of the disease, in addition to also realizing health equity indicators [25].

Academic Education Challenges

Many studies have been conducted on the inadequacy of palliative care training in various medical groups, mostly targeting nurses and physicians. Some of these studies have suggested that nurses are still inadequately skilled and not very efficient in providing palliative care and that they require better training for this particular concept and type of care [26].

The main problem of the nursing system in Iran in relation to palliative care for cancer patients is that no clear framework exists for this type of care for nurses and that it does not have a strict presence in the official curriculum. One reason for this problem appears to be the lack of comprehensive studies on this subject in the country, which limits the applicability of the concept of palliative care to these patients [27]. Findings of a study conducted for “examining the attitude and motivation of nursing students for finding work in cancer departments” showed that nursing students did not have a positive attitude toward working in cancer departments, and showed their mean overall score for attitude toward working in cancer departments and all of its components to be low. The incompatibility of the content of theoretical courses on cancer and the real needs in cancer departments ranked lowest among all motivational factors. The lack of adequate communication and care skills for patients at end-of-life stages and the incompatibility of the content of theoretical courses on cancer and real-life needs had contributed greatly to the students’ negative attitudes [28].

In many countries, General Practitioners (GPs) are the main responsible authorities for providing patients with medical care, in particular palliative care. In Iran, given the extension of the role of GPs to family doctors, it appears that they will also play the main role in this area. However, there is no formal palliative care training in Iran during the course of general practice education [6]. Results of a study show that, in Iran, only 12 % of GPs have excellent or very good knowledge of palliative care and more than half of them have poor or no knowledge in this area. Only 22 % of participating physicians knew about the WHO pain control guidelines and were well acquainted with the management of patients’ physical symptoms. More than half admitted their poor knowledge of pain control, the principles of end-of-life care and palliative care. It appears that the deficient knowledge of physicians on palliative care is rooted in the medical education system in place in Iran, which is mostly symptom based rather than holistic [6].

Despite the guidelines provided by the World Health Organization on the management and treatment of pain in cancer patients, pain is still not well managed in these patients. A main barrier to the control of pain in these patients is the physicians’ deficient knowledge. In a study conducted on this subject, the main barrier to the proper management of pain was the absence of pain control specialists and the personnel’s lack of knowledge on pain management. The majority of physicians who participated in this study asserted that they were unhappy about the pain management training they had received during their medical education [29, 30].

Given the importance of a well-established, specialized workforce for providing this type of care, and in response to the shortage of human resources at both general and specialized levels, educational planning for the required disciplines has been given priority in the National Bylaw for the Development of Palliative and Supportive Cancer Care (2012), and it has been proposed to develop an educational curriculum, as well as short-term and long-term course requirements, and to issue certificates by the deputy and office of continuing education in the health professions [21].

The Interrelationship Between Cancer Care and Local Culture and Society Reactions to Cancer Patients

In every society, cancer care is affected by the prevailing culture of that society, and the attitude of people in that society toward health and disease affects how that society treats and regards patients. Some of the cultural challenges present in the Iranian society in treating cancer patients are discussed in the following section.

Telling the Truth to the Patient

Cultural elements affect the patients’ reactions to being diagnosed with serious diseases such as cancer and the decisions they make about end-of-life care. Studies conducted on this subject identify three fundamental dimensions for end-of-life care and treatment as affected by cultural issues, including the manner of breaking “bad news,” the locus of decision-making about treatment procedures, i.e., resort to the available options or discontinuing treatment, and people’s attitudes toward end-of-life care [31].

Contrary to the emphasis in Western culture on truth-telling, in some cultures (such as in the Middle East, and more specifically, in Iran), it is not uncommon to hide the cancer diagnosis from the patient, and disclosure of cancer might be misconstrued as bad manners, disrespect, or even detrimental [31, 32]. For example, in Iran , in some cases, the patient might only learn about his disease long after his definitive diagnosis of cancer, and even then only indirectly through chancing upon his medical file, talking to other patients, starting treatments such as chemotherapy; under most circumstances, the diagnosis is not directly disclosed to the patient [33].

Although in many societies, decision-making is based on the patient’s autonomy and freedom to act, in some cultures, medical decisions are still doctor-oriented or doctor-family oriented, which might violate the patient’s autonomy. Some cultures (such as most Asian cultures) value the principle of productivity and usefulness more than autonomy and freedom to act. Consequently, in many of these cultures, care providers tend to hide cancer diagnoses from the patients. In such cultures, physicians obscurely express the severity of the patient’s condition by using medical jargon, and only disclose the information to the patient’s family members [31, 34]. In these cultures, the majority of people believe it a pointless cruelty to tell the patient directly that he has cancer [35]. In some Asian cultures (such as in Pakistan), the patient’s family members deliberately and actively protect him from the burden of finding out about his end-of-life conditions. In these cultures, disease is mostly a family event rather than a personal one, and it is often preferable if the family takes care of the patient (particularly during the end-of-life stage) [36].

There are major reasons for which cancer is not disclosed in these cultures. In some cultures, for example, talking about death and serious diseases is considered disrespectful and a form of bad manners. Some believe that freely discussing cancer and serious diseases causes unnecessary depression and anxiety in the patient. Some believe it to lead to the loss of hope in the patient. In some cultures, there is even the belief that hypothetical discussions about death and terminal illness might turn them into reality [31]. Moreover, the common belief is that if the patient learns about his diagnosis, his condition will worsen [19].

As a general rule, the less people know about a subject, the more infused with myths and mysteries will be their interpretation of it. Cancer is one such subject. False beliefs and myths are not merely a wrong notion that sticks in minds; they also affect people’s tendencies in life. For years, cancer was considered an inevitable cause of death. It is therefore not surprising that there are so many myths about it. Some of the myths that are more common among the general public are that a cancer patient has a tragic fate, or that cancer surgery spreads cancer throughout the body [19].

Such points of view are also observed in the structure of health systems. For example, cancer departments are often located in the worst areas of hospitals and in old, dark, dingy places with no particular design and beauty, while a beautiful, green architecture can significantly improve healing in these patients [37].

Death and Dying

Iran is a country where 98 % of the population is Muslim. Death is a well defined and essential concept in Islam. In Iran, death is culturally well defined and dying is considered a rebirth as part of the stages of life [38]. In the Iranian Islamic culture, pain or painful death are considered atonement for sins committed in life. This view of death leads to the more devoted performing of religious rituals and practices during times of critical illness and end-of-life stages. From a cultural and religious perspective, placing the Quran above the patient’s head or by his bedside is one thing that brings the patient peace, even in the form of a peaceful death [18]. Given the increased emotional and spiritual needs of patients in end-of-life stages, which brings intense psychological reactions in them, care providers try to support the patients and their families both emotionally and spiritually so that they can be better prepared and adapted to their conditions [39]. Most people turn to religion to improve the patients’ psychological health for facing tensions caused by disease and potential death [40]. In religious societies like Iran, death is deemed “the Will of God,” which is a consolation that might result in the acceptance of fate. In other instances, the well-known metaphor “the Will of God” is only used when every hope in medicine is lost [41].

Given what has been said about Eastern and Asian cultures, the common opinion in Iran emphasizes the providing of care for cancer patients in their own homes (particularly for those in end-of-life stages). However, there is still no research-based evidence to suggest what the preferences of cancer patients are in Iran [42].

Local Innovations and Palliative Care

Because of the complexities in the diagnosis, treatment, and symptoms of the disease, cancer patients have complex care needs through all the stages of the disease, from diagnosis to treatment and during the follow-up to the end-of-life stage. Because of its vast scope of effects on the various aspects of the patients’ (and their families’) life, including the physical, psychological, spiritual, and social aspects, cancer requires a holistic care [4].

Holistic care considers all the needs of the patient and requires a coordinated multidisciplinary care team. In holistic care, extensive services are provided for the patients and their families, including treatment and management of symptoms, training, counseling, support groups (emotional, psychological, financial, etc.), and other special programs designed to help improve quality of life in the patients and their families [43].

The early diagnosis and treatment of cancer can significantly reduce cancer mortality rates. For achieving this goal, it is necessary for countries to make proper use of each others’ experiences and innovations in fields concerned with cancer care, such as medications, diagnostic and treatment techniques, and modern care models [44].

A large proportion of cancer care is provided to patients in the form of palliative and supportive care. In Iran, palliative and supportive care is a relatively new concept and providing such services to cancer patients is in its infancy. In terms of providing palliative care, Iran is classified under group A3. In countries of this group, palliative care is provided sporadically and is not well supported; for the most part, it is a type of care provided at the patients’ home, and the ratio of available service centers to the population is very low [30].

The need for providing palliative and supportive care in Iran is a well-perceived need [30], and the absence of the documented providing of these services has created countless problems for both patients and the Ministry of Health, including patients’ frequent visits to emergency departments for the management of symptoms, their frequent admissions to ICU and other departments and the increased rate of nosocomial infections. However, only 20 % of cancer patients require specialized services to manage their symptoms, and 80 % can manage their problems through primary care. At the present time, palliative and supportive care services are only provided in a limited number of centers across the country [45]. Following the implementation of the plan for the development of a Comprehensive National Supportive and Palliative Cancer Care Program, which was carried out in 2012 under the supervision of the Department of Non-Communicable Diseases, the Cancer Department of The Ministry of Health and the Iranian Cancer Research Network and in partnership with associated science associations and research centers, the “National Bylaw for the Development of Supportive and Palliative Cancer Care” was complied in seven chapters. This bylaw defines the levels of supportive and palliative care providing as composed of the hospital unit, the counseling team, the clinic and the home care team [21].

Modified and localized models commonly used in other countries at the regional and international levels can also be considered suitable models for Iran that can be adapted from their successful programs in this area. For example, in these countries, palliative care is provided in various centers such as palliative care departments in hospitals, hospice facilities, and community care centers [46]. As for Iran, considering the available resources, the health system and the different composition of the Iranian society, appropriate systems of providing care for cancer patients can be effectively adapted from western care systems and instituted in such areas as the establishment of palliative care departments, providing home care, day-care clinics, and hospice facilities (if practical). The NHS has developed a stratified support and care model for patients with cancer, which is helpful in providing holistic care and meeting patients’ other needs in addition to needs associated with the disease and its effective treatment. This care model is an innovation in cancer care, and adapting it can be effectively helpful in providing care for cancer patients in Iran [47]. Based on the investigations conducted by a panel of experts on the structures of providing palliative care in Iran, which take into consideration criteria such as health infrastructures, social, cultural, and economic conditions and the availability of equipment and facilities in the country, it appears that the techniques for providing hospital care, home care, and hospital counseling are higher priorities. Providing palliative care is not a priority or a necessity in day clinics across Iran. Hospice facilities are centers in which providing palliative care is of the lowest priority [48].

A helpful and seemingly essential action in providing proper holistic cancer care is to record the medical history of patients, to utilize information technologies, and to create electronic files for patients. Electronic filing is very helpful in coordinating the providing of care among different members of the care providing team [49]. Modeling our country after western health care systems with their valuable experiences in this area can help improve cancer care in Iran. Cancer care requires close interdisciplinary teamwork. Interdisciplinary care does not have a long history in Iran. Using the positive experiences of western countries with long histories in this area also helps accelerate the improvement of palliative care in Iran.

Undoubtedly, an important point to consider in the providing of care for cancer patients is the availability and accessibility of medical resources that can be used along with financial support and better payment methods for the patients. The cost of cancer care and treatment is too high (in Iran and also in many other countries), which deprives many low- and middle-income patients from proper care [50]. One of the measures that have been taken in the Iranian health system to improve this deficiency is the Healthcare Transformation Plan that launched last May. According to this plan, patients with refractory diseases such as cancer are to benefit from major help and support from the state (in particular the low-income patients), so that they do not encounter problems during the course of their treatment. This plan has increased the patients’ satisfaction, reduced part of their costs, and provided the means for better care. If the plan turns out to be successful, the health system of other countries can also perhaps adopt it for their own benefit [51].

Government’s Share in Cancer Patients’ Care

Before addressing the government’s share in cancer patients’ care, it is essential to provide a brief overview of the health system in Iran . Article 29 of the Constitution of the Islamic Republic of Iran states that every Iranian citizen has the right to benefit from the highest possible level of health. To accomplish this level of health, in Iran, the Ministry of Health and Medical Education is given responsibility for the design and implementation of national health policies. The Ministry of Health has delegated the implementation of these programs to universities of medical sciences throughout the country. Each province of Iran has at least one university. The head of the university of medical sciences is the highest responsible authority in each province and reports to and is accountable toward the Ministry of Health and Medical Education. He is also responsible for the public health, for providing facilities for the public health and for medical education. Health care and public health services are provided through a national network, from primary to tertiary health services [24] (Fig. 20.1).

Fig. 20.1
figure 1

The health system network in Iran (adapted from: Mehrdad R. Health system in Iran. JMAJ 52(1): 69–73, 2009.)

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Over the past two decades, the government has placed a greater emphasis on public sector primary care services. Some health care services, such as vaccination and prenatal care are provided free of charge. The public sector also provides a significant proportion of secondary and tertiary health care services in provinces [24].

The private sector plays an important role in providing health services in Iran. Most private sectors are located in urban areas and focus on providing secondary and tertiary health care services. There are many nongovernmental organizations (NGOs) in Iran that are active in the health sector. NGOs are often active in specific fields such as children with cancer, breast cancer, diabetes, and special diseases like thalassemia and hemodialysis patients. The Ministry of Health and Medical Education is responsible for planning, monitoring, and supervising the health activities of both the public and the private sectors [24].

Iran’s ministry of health has a unique structure that distinguishes it from ministries of health in other countries. In 1986, the integration of the ministry of health and the higher education system created the present ministry, referred to as the Ministry of Health and Medical Education. The proponents of this integration believe it to have strengthened the quality of health services throughout the country, while its opponents believe it to have adversely affected medical education. However, in the absence of systematic studies for proving the standpoints, the controversy over the integration remains unresolved [24].

According to the official data, over 90 % of the population of Iran are covered by at least one type of health insurance. The main health insurances include Social Security Insurance, Iran Health Insurance, Armed Forces Insurance, and Imam Khomeini Relief Foundation [24]. Public state funds and health insurance payments are the main sources for health financing in Iran. The state fund is proposed by the Ministry of Health and is confirmed and approved by the Parliament. Insurance payments are provided by four health insurance organizations and are somewhat state dependent and variously supported by the state. However, the Iranian health system aims to reduce payments made by people (out-of-pocket payments) to 30 % in the next few years [23].

To better understand the system, the process of money circulation in the Iranian health care market is shown in Fig. 20.2.

Fig. 20.2
figure 2

Money cycle within the Iranian health care market (adapted from: Davari M, Haycox A, Walley T. Health care financing in Iran; Is privatization a good solution? Iran J Public Health: 2012,(7) 41.14–23)

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Given the stated points about the health care system in Iran, the extensive share and interference of the state in patients’ health care is inferred. In Iran, care services provided to cancer patients are generally hospital based. In other words, the majority of patients receive their health care in hospitals and centers providing home care are rare and hospice facilities are simply nonexistent in the country. These patients can receive the care they need in hospitals and public centers (in most cases) or hospitals and private centers (in fewer cases). As indicated by the role of the state and the Ministry of Health in planning, monitoring, and supervising care services provided to patients in public and private hospitals and even nonprofit hospitals and charities, the government’s substantial share and interference in providing every aspect of care to cancer patients, including diagnosis, treatment, and rehabilitation, is prominent [23, 24].

Institutional Involvement

In the prevention of and fight against cancer, early diagnosis, proper treatment, and after-treatment care, public institutions and NGOs contribute greatly with their cooperation and coordination. The costs of diagnosis, treatment, and controlling of cancer are outrageous and become even more so by day, to the extent that even middle-income patients cannot afford the cancer care they need. In all countries, including developed ones, nongovernmental charity organizations vastly contribute to the supporting of cancer patients and governments do not consider themselves well-to-do without the help of these institutions. Governments therefore try to provide the appropriate framework for the establishment, growth and prosperity of NGOs and for their providing of services to patients [50]. NGOs active in the field of cancer can play a major role in the development and implementation of government policies, including the Comprehensive Cancer Control Plan, and can also undertake a significant share of the state responsibilities through promoting good life habits and warning about bad health behaviors and providing inclusive support to the patients and their families.

In the Islamic Republic of Iran, with the rich national and religious culture it boasts, several charities have been organized in the majority of provinces to help support cancer patients and provide care to them. Some of these organizations have a long, illustrious history of supporting cancer patients and their families and provide valuable diagnostic, palliative, and treatment services to cancer patients through their establishment of medical centers such as radiation therapy centers, hospitals and physical and mental rehabilitation centers. Some of these charity organizations have undertaken remarkable activities toward the prevention of cancer and its early diagnosis through providing financial support or through informing and educating the public and promoting awareness in the community [50].

There are nonprofit medical institutions in the form of hospitals or radiation and chemotherapy centers for cancer patients in major cities of Iran, including Tehran, Isfahan, Mashhad, Shiraz, Hamadan, and Urmia, bearing a significant share of the government’s responsibility. Charity associations for supporting cancer patients also exist in many other cities of Iran; however, they may not be as extensive as the institutions existing in major cities, and might not be well equipped with treatment and diagnostic centers; yet, they provide notable financial and spiritual support to cancer patients and contribute effectively to their care [49]. These institutions are not merely about providing financial help; rather, they have always directly cooperated in providing care. Examples include Mahak Charity, which provides palliative and treatment care for children with cancer, and Sepas Charity, which provides psychosocial support for cancer patients. Seyed-Al-Shohada palliative care center of Isfahan is another example of charity centers that are active in providing completely free of charge care to cancer patients. The expenses incurred by patients are fully paid for by people’s donations [30].

A non-extensive list of NGOs participating in cancer care in Iran follows: Mehraneh Cancer Care Charity in Zanjan, Kurdistan Cancer Patients Supporting Society in Sanandaj, Iranian Cancer Society in Babul, Aria Breast Cancer Society, Iranian Lung Cancer Society (ASRA), Behnam Daheshpour Charity in Tehran, and many others.

Other than charity organizations, some centers in affiliation with universities and a number of public organizations also play a major role in providing care to cancer patients. The National Cancer Institute, which is under the coverage of the Charity Foundation for Special Diseases, began its activities with an independent charter in 2009, aiming to prevent cancer and help improve cancer patients’ health through a network of specialists and volunteers at the national level and the cooperation of relevant organizations. This institute aims to establish a medical center in the next few years [52].

Among other official organizations affiliated to universities of medical sciences and playing an active role in providing care for cancer patients in Iran are the designated cancer research centers that provide significant care services for cancer patients. For example, the Cancer Research Center affiliated to Shahid Beheshti University of Medical Sciences performs extensive activities in applied research for cancer prevention, for the proper treatment of cancer patients and for their care and rehabilitation. These research centers carry out screening projects for some cancers (breast and cervical cancers) in the form of research projects that have proved very useful in the early diagnosis and treatment of cancer and reducing its mortality rates. This center also provides free counseling services for cancer patients. For instance, this center holds free “stress reducing techniques” seminars for patients and is launching palliative and supportive care services for cancer patients visiting this center [53]. Other research centers of the type also exist in other major universities and cities of Iran.

Although charity and nongovernmental centers and institutions and nearly independent centers and institutions affiliated to universities are more or less active in providing care for cancer patients, their share is still negligible compared to the government’s share. Further developing the means for the expansion of these institutions in providing care to cancer patients requires the government’s assistance, the removal of the legal barriers against the activities of these institutions, and simplifying legislations on matters such as customs and tax [50].

Conclusion

All countries should deploy the core essentials of the health system and information systems required for monitoring and evaluating planned epidemiological data, and should then use these data for a better decision-making. Countries with low to moderate resources such as Iran should consider the key priorities of their region. With any degree of resources at one’s disposal, taking a stage-by-stage approach allows every priority to be considered in both the plan’s content and the geographical field. Furthermore, cost-effective sustainable technologies should be used in conditions where resources are limited. For Iran, inexpensive and effective maintenance care is the start point that will gradually lead to the adoption of a holistic approach entailing early detection and primary prevention. The priority for actions in maintenance care should be based on the resources of the country, and should target the implementation of comprehensive maintenance care programs in order to improve quality of life in numerous cancer patients or to improve other life-threatening states of theirs and their families’. These programs should improve pain, control other symptoms and provide psychosocial and spiritual support. Under such circumstances, it is essential to ensure that the minimum standards of pain improvement and maintenance care are progressively in place at target areas and at all levels of care; high levels of health service coverage is mainly achieved in the form of home care at these stages. In countries with strong family support systems and poor health infrastructures, home care is the best way to achieve a good quality of care and is the best form of health coverage [54].

Palliative and supportive cancer care has recently become the main focus of attention in Iran as part of the country’s National Cancer Control Program. Priorities set by the World Health Organization in this area include increasing sensitivity to the need for palliative services at all levels, providing services and introducing palliative services to physicians and nurses, providing pain reducing palliative services, controlling other symptoms, providing psychological and spiritual services and ensuring that minimum standards for palliative care are in place. As for increasing sensitivity to palliative care, effective actions have been taken, such as holding conferences and workshops among policy makers and introducing palliative care services to physicians and nurses and other groups concerned. Although there is still a long way to achieving desired services, activities that have recently begun, and the position of palliative care as one of the priorities of the National Cancer Control Program, promise the development of these services in Iran in a future not too far away.