Funding fertility: issues in the allocation and distribution of resources to assisted reproduction technologies

The appropriate level and source of funds for assisted reproduction technologies (ARTs), in particular IVF, have been controversial in most developed economies. Funding of fertility services internationally is characterized by low public (or other third party) funding, a greater reliance on user-pays than in most other health services, and variations in funding and provision. This article describes the characteristics of infertility as a condition and its treatment that have been used as a rationale for its exclusion from an otherwise comprehensive coverage of health services. The challenges these characteristics pose for the use of economic evaluation to inform resource allocation are discussed. Most economic evaluations have focused on the cost effectiveness of alternative infertility treatments. These evaluations provide important information, but do not inform the real issue at stake: what is the appropriate allocation of funds to ARTs, given that it involves sacrificing improvements in health in other areas? Cost utility analysis - the method of economic appraisal preferred by most agencies charged with making such decisions (including the National Institute of Clinical Excellence in the UK) - is ill-equipped to deal with the benefits produced by ARTs. Alternative methods are available, but require decision makers to weigh up very different sorts of evidence. Demonstration of the willingness to pay for the benefits of ARTs can be used to support public decisions but, conversely, also implies that those who can pay will pay in a private market. Ultimately, decisions about the inclusion or otherwise of ARTs in collectively funded health systems probably rest as much on judgments about equity in access as value for money. Given that this is the case, public funding of IVF should be accompanied by the development of agreed criteria for the prioritization of potential recipients, to ensure treatment is targeted at those for whom it is most effective and that access is consistent and fair.