Equity and access are among the most urgent issues for medically assisted reproduction. According to Ireland's Health Research Board, across Europe six countries offer full public funding (defined as 81 percent or more per cycle) and 19 countries offer partial public funding (between one and 80 percent). The countries that provide partial or no public funding require substantial out-of-pocket payments from patients wishing to access treatment.
Over the last decade, more countries are providing public funding for assisted reproductive technologies (ART). Yet levels of funding have been reduced and patients are making more out-of-pocket payments. The number of cycles funded through public health services varies from country to country, from one cycle in Northern Ireland (see BioNews 922) to an unlimited number of cycles in Australia.
The European Society of Human Reproduction and Embryology (ESHRE) has looked at the issues of equity and access in cases of infertility. It concludes that fertility treatments should be at least partially reimbursed in relatively affluent countries, based on the impact of not being able to have a child on the quality of life of a person.
Equity and access in Ireland
Currently no public funding is available for fertility treatment in Ireland. Access to services is based on ability to pay, which openly discriminates against the less wealthy.
A draft of the Assisted Human Reproduction Bill was presented by Ireland's Minister for Health, Simon Harris, this month, with proposals of state funding for fertility treatment to follow by year-end (see BioNews 917)
The Bill will include provisions covering assisted human reproduction and associated research; establishing a specific regulatory authority for assisted reproduction including surrogacy, embryo and gamete donation, preimplantation genetic diagnosis of embryos, and stem cell research.
The proposed legislation will not contain details of public financing for assisted reproductive services. However, a review of international funding of reproductive services by the Health Research Board, Ireland has been conducted at the request of the Minister for Health. This will guide decisions on accessibility in terms of public funding, clinical and social criteria.
Internationally, healthcare budgets are strained. Technological advances and expanding healthcare systems, as well as ageing populations and increasing prevalence of lifestyle related illnesses (such as obesity and diabetes), are leading to escalating costs.
As highlighted in 2010 by Ireland's Department of Health Expert group on Resource Allocation and Financing in the Health Sector: 'A key challenge for many countries is how to finance healthcare in a way that is equitable, affordable and promotes good health.'
The report recommends an overarching framework to optimise the contributions of each part of the healthcare system with the aim of optimising 'accountability, efficiency, governance and clinical care'. It emphasises the need to prioritise patient autonomy and equitable distribution of resources.
ESHRE argues that successful infertility treatment allows people to express their autonomy, by enabling their reproductive choices with the subsequent benefit of increased wellbeing and general health. Limiting access to treatment on the grounds of ability to pay is discriminatory and unacceptable if procreation is considered part of fundamental health.
An ESHRE taskforce has suggested that policymakers introduce regulation to set costs for fertility treatment cycles. Variability in the cost of IVF cycles is seen in England where different CCGs commission services from different clinics, contributing to a fertility service-funding crisis (see Bionews 913).
Healthcare rationing in the area of assisted reproduction is complex, not least because reproductive medicine does not lend itself to standard cost-effectiveness analysis in assessment of value. It is difficult to place a value on the generation of a human life, and on the improvement of the quality of life and general wellbeing of the parents.
Joseph Schenker, professor of obstetrics and gynaecology at the Hebrew University of Jerusalem, has a particular interest in the ethical aspects of reproduction and gynaecological medicine and works with the ethical committee of The International Federation of Fertility Societies.
In his book, 'Ethical Dilemmas in Assisted Reproductive Technology', he contends that different funding arrangements in countries '… Illustrate the intrinsic relationship between sociocultural and moral norms and the allocation of healthcare resources to ART treatment', and that 'Funding arrangements illustrate society's sensitivity to aspects of ethical and distributive justice with regard to ART.'
Schenker advocates single embryo transfer as the gold standard. He gives examples of Australia, Belgium and Sweden as countries achieving good standards of clinical practice, using single embryo transfer against a backdrop of public funding for assisted reproduction. He emphasises that policymakers need to be aware that inequity of access based on ability to pay impacts clinical management of women and babies' clinical outcomes.
There is a wealth of international funding data available from Ireland's Health Research Board's evidence review, 'Assisted reproductive technologies: International approaches to public funding mechanisms and criteria'.
This comprehensive review concludes that 'national policies are a hybrid of political, cultural and economic pressure combined with clinical evidence leading to a publicly acceptable or pragmatic approach to funding assisted reproductive technologies in each individual country examined'.
A regulated reproductive service in Ireland is long overdue. Maybe the extra time taken to reach this point will benefit the service in the long run, in that its future public funding structure can be informed by international experience as documented by HRB (Human Research Board) and ESHRE recommendations. These recommendations include at least partial public funding in relatively affluent countries, a funding structure that can enable efficient, safe and equitable treatments, and setting a fixed number of cycles for individuals and couples who meet the required clinical and social criteria. ESHRE also highlights that practitioners have an obligation to reduce the costs of treatment as far as is practical.