This study analyzed data to compare infertility care policies among the selected countries representing lower middle-, middle-, and high-income countries including Ghana, Iran, Turkey, United Kingdom, Australia, United State of America, and Singapore. We analyzed the data based on the universal health converge framework including assessment of different aspects of its three dimensions that were financial protection, population converge, and services features.
The findings, generally, indicated that countries that are financially stable had better policies on infertility services. However, among rich countries, infertility care policy in the USA did not show a high score as expected. It is argued that the current situation in the USA might be due to the fact that infertility is not considered to be a disease by the USA government and thus support for those with infertility is limited. Similarly, in poor countries with limited financial resources where governments are struggling with the burden of infectious diseases, injuries, and high neonatal mortality and severe malnutrition, infertility services are very expensive and are not given priority [46,47]. Thus it is obvious that the use of assisted reproductive technologies for the treatment of infertility is an ongoing global reproductive health problem in both low and high income settings [2].
The other issue that should be discussed is the issue of equity and responsibility in the health system on infertility care. In countries in which infertility is not recognized as a medical condition or a human and reproductive right, not favorable comprehensive policies and services could be observed [33, 49,50]. Such insufficient policies might cause limited financial protection for providing infertility services and perhaps would increase the financial burden to infertile couples and their family. Studies showed that there are considerable inequalities in access to effective treatments in countries such as the United States and Ghana [7, 29].
The role of population policies in addressing infertility programs is very important. After a prolonged Total Fertility Rate (TFR) decline due to family planning and socioeconomic factors in many developed and developing countries, some of these countries introduced pronatalist incentives [51]. As shown in Table 1, Australia, Singapore, and Iran have the lowest TFR among other countries. In these countries, strong pronatalist narrative policies have been formulated [51-53]. The justification for such policies is the fact that governments think support programs for infertility care could be a strategy to help to increase the population. For example, in Iran, the Ministry of Health is committed to infertility treatment and has mandated insurance companies to cover the cost of therapeutic and diagnostic tests and to subsidize the price of drugs for the treatment and has expanded the public infertility clinics [28].
Generally, progress in life expectancy, survival values, gender equity, and community values are viewed in countries that have a favorable condition in UHC on infertility services. This emphasis the hypothesis that if human rights, life expectancy, and survival were valuable in a population, then appropriate policies for UHC will possibly be presentable and there may be forceful mechanisms for agenda-setting in emerging conditions such as infertility [54]. In addition, attention to infertility services is very much related to the development goals of countries. For example, in Japan with 2,400,000 infertile individuals [55], presence of numerous infertility clinics (518 clinics in 2016), the existence of adequate laws and protocols related to infertility services, the existence of full insurance and government funding, show the importance of increasing the youth population for economic activity and development [25].
Social concerns about the use of third-party involvement in ART could be a barrier for acceptability and service coverage [23, 28, 56]. Additionally, major challenges are seen in providing preventive and supportive infertility care in communities where cultural, religious, and social complexity exists. On-demand side, infertility related stigma in many societies has led to the reduction in seeking supportive care services [57,58], sexual health education, and STI care, which are the main foundations for the prevention of infertility [59,60].
Neglecting infertility in the long term can be lead to population decline and aging. It is argued that this could be happen due to several reasons including the decrease in timely marriage, and fewer new births. However, these by itself can increase the burden of health care systems. Likewise, remaining untreated infertility or failure of preventing it, might double the cost of the health care system [61].
Responsiveness to equity in allocating financial resources to infertility, which are related to future economic development and growth, is important in lower middle- and middle-income countries with limited national resources. So, by using appropriate insurance coverage, efficient resource allocation strategies in health care and adequate funding strategies, it is possible to reduce the share of out-of-pocket payments and equity in allocating financial resources for it [62]. Therefore, paying attention to the implementation of appropriate policies to prevent infertility, timely treatment and rehabilitation of couples for proper childbearing, can be an appropriate policy to invest in creating a productive and economically active generation to grow and improve Gross Domestic Product (GDP) in the future.
However, our study had several limitations, for example, in some countries, such as Turkey, some policy documents and programs were not available in English. Also, all documentation in many countries might not be online and therefore inadequate access to the national documents and lack of comparable studies was the main limitations.