Infertility policy analysis: a comparative study of selected lower middle- middle- and high-income countries

The policy documents were defined as all formal records and reports that were written by national governments, national scientific communities and academic societies, national authorities and international organizations’ decisions, reports, plans and actions such as World Health Organization, World Bank, world health statistics, world development indicators and demographic and health survey. The type of evidence are as follows: provincial annual reports, core public health function/standards documents, health human resources (HHR), human resource planning (HRP) annual reports, business plan, commissioning policy documents, clinical guidelines, health profession legislation, and other public health (PH) reports such as competency development and leadership frameworks. Newspapers, online advertising sites, movie content, and marketing channels were not being included.

In order to select countries, after an initial search, we selected 14 countries that had available policy documents related to the three dimensions of universal health coverage that are prevention, treatment, and supportive care for infertility services. However, the final selection of countries was based on the following criteria:

As such seven countries including Australia, the United Kingdom, the United States of America, Singapore, Turkey, Iran, and Ghana were selected. The flowchart of the selection of the countries is shown in Fig. 1.

An electronic systematic review search was conducted using PubMed, Scopus, ISI, Google Scholar, Google, all public websites, websites of health ministries, and websites of infertility clinics. Keywords included infertility, policy-making, affordability, accessibility, availability, acceptability, awareness, treatment, insurance, health policy, prevention, financial management, childlessness, equity, utilization, and cost. The search was conducted for each selected country. The search was limited to year 1994 to end of 2019. The year 1994 was chosen because since then the Cairo Conference has recommended countries to plan and implement action to prevent and treat infertility. Irrelevant documents were excluded. For instance, discussion papers, advertisements, and video clips were excluded. The study flowchart is shown in Fig. 2.

A datasheet was prepared including the following information: name and aim of the policy, author(s) or organization name, and actors involved. These were tabulated and made ready for further analysis. Then, we identified three components for each policy document as defined by universal health coverage (UHC) in three scopes (prevention, treatment, and supportive care). These were: 1) financial protection 2) population coverage 3) and service package [13, 14].

Finally, the indicators and practical definition of policy components were provided and was finalized in two sessions by an expert panel consisting of two specialists in health policy, two public health scientists, a gynecologist who specialized in reproductive endocrinology and infertility and a reproductive health specialist. The explanatory variables and indicators are described in Table 1. Then a scoring manual for the three dimensions of universal health coverage that were related to the infertility policy for each selected country was presented. For each dimension, a description of the scoring is presented in Table 2.

A profile of the selected countries is presented in Table 3. These included a range of information from the gross national income per capita to the fertility rate for each selected country. As shown, the prevalence of infertility rates ranged from 12 to 20% [15‐21]. Comparing the cost of infertility treatment in countries showed that Singapore had the most expensive services for IVF treatment at 10000 to 15,000 USD for each cycle, but most of the costs (95%) are paid by the Medicare system [22]. On the contrary, Iran had the lowest IVF treatment price of 1272 USD per cycle [2].

The flowchart is depicted in Fig. 1. In all 287 policy documents were retrieved for the selected countries, of which 183 irrelevant documents were excluded. The remaining 104 documents were examined for the components of universal health coverage, which are described in the following sections:

The financial protection was inadequate in Ghana, and the USA, intermediate in Turkey and Iran, and good in Australia, the United Kingdom, and Singapore. For instance, all IVF clinics in Ghana are private, and there is no insurance coverage for infertility treatment. However, there are two voluntary and non-profit organizations that assist those who are at desperate need [23]. In the United States, there is no government service for the treatment of infertility. In only 15 states, the treatment of infertility is covered by private insurance [9, 24]. Specific limitations in the funding of Assistant reproductive technique (ART) were indicated for Turkey, such as offering funding based on fertility status that only primary infertility is covered by insurance [25]. In the UK, the National Health Service (NHS) provides infertility services and all patients have the right to be referred to an NHS hospital for the initial investigation, although waiting lists for treatment can be very long in some areas. In Australia and Singapore, the government provides infertility services under the Medicare system [22, 26, 27]. In Iran, insurance companies cover 20 to 80% of the cost of medical and diagnostic tests for infertility and pay fees for medications in primary and secondary infertility. Also, in the registry system, the government support package included two Intrauterine Insemination (IUI) and one IVF cycle in public centers has become free of charge since 2017 for couples who were eligible [28]. Table 4 presents the findings.

We examined infertility policies for converge to suggest whether infertility care covers both males and females, include different age groups, and offered to those who are living in urban or rural areas in the selected countries. In Ghana there is no governmental infertility care service at all. In addition, since there is a general belief in Africa (including Ghana) that men are not infertile; therefore, there is no adequate information about male infertility and related health services [29]. However, infertility services that are provide in the private sector for women, have no age limit. Iran and Turkey have comparable position on population coverage, such as providing infertility treatment for both men and women, and have age limit in the therapeutic process for women (less than 42 in Iran and 39 years in Turkey) in the governmental sector. In Iran, the government support package reserved for primary infertility and secondary infertility in a new marriage [30‐32]. There was no evidence of difference in care provision between men and women. In the USA a growing body of literature shows that access to male infertility care is limited by several factors [33]. Most infertility clinics have age limitations for women (37 years or younger) [34]. Also the National Health Service in the UK provides infertility treatment for women with age limitation (up to three full cycles of IVF will be offered to eligible couples where the woman is aged between 18 and 39 and 1 cycle for where the woman is aged 40–42 years.) [35]. The service coverage that is urban /rural coverage were found to defer in the selected countries. The findings are presented in Table 4.

As of 2015, in Ghana, only 14 private clinics are offering ART for nearly 6 million women in reproductive age (15-45 year). Unfortunately for the treatment of infertility, many women chose traditional healing and mediation [23, 29, 36]. The ART services are provided in 46 private and 44 public clinics in Iran, but none of them have registration systems or reporting transparent successful rates, most of which are in Tehran, the capital [25]. Currently, there are over 130 fertility clinics operating in Turkey. A number of fertility clinics are located in public or teaching hospitals, but most are private. They are mostly located in big urban areas [25]. There were 74,357 ART treatment cycles reported from Australia in 59 private physician clinics, 12 private hospital-based clinics, and 5 public clinics in 2016 [25, 37]. Based on CDC’s 2017 Fertility Clinic Success Rates Report, there were 284,385 ART cycles performed at 448 reporting clinics in the United States during 2017. These clinics are located throughout the country with a density in the west [38]. In Singapore, eleven infertility treatment centers are in the south [25]. All 78 infertility clinics in the UK are private or teaching hospitals [25] and the referral system in NHS that presented by a general physician are helpful for better accessibility and affordable services.

Impending health care reform for the Infertility Prevention Project (IPP) is working on multiple levels (federal, state, and local), within and across the USA, but there was no supportive care plan for infertile couples [39]. The Academy of Medicine (AMS) and the Ministry of Health (MOH) in Singapore have developed the clinical practice guidelines for assessment and management of infertility at the primary health care level for prevention proposes [22]. In the UK screening and prevention programs such as educational interventions are supported by the NHS and the Department of Health and Social Care [40]. Additionally, psychological, social, and financial support is provided by the NHS and volunteer groups [41]. Australian and New Zealand Infertility Counselors Association, Australian general practitioners, and Australia’s National Infertility Network have several educational programs for prevention and supportive care [26, 42‐45]. In the other three countries (Ghana, Iran, and Turkey) we did not find any document for prevention or supportive care. The final score of the infertility policy situation of the selected countries is provided in Table 4.