Expanding access to assisted reproductive technology in a developing country: getting more for less.
Abstract
Background: Infertility is a universal health burden with profound consequences in low/middle-income countries (LMIC). The global prevalence of infertility is between 8-12 % with values as high as 32 % in Central and Southern Africa, often referred to as the “infertility belt” [1]. In Nigeria, a prevalence rate of between 20-30% has been estimated due to the high prevalence of sexually transmitted infections [2]. The consequences of involuntary childlessness in a low/middle-income country can be devastating, leading to economic deprivation and impoverishing medical costs [3]. There is a high premium placed on childbearing in developing countries due to the socio-cultural beliefs and practices, yet there exists a high disparity between urban and rural dwellers with respect to accessing health care [4].
Challenge(s): There is an unmet need for assisted conception in sub-Saharan Africa as published data suggest less than 1.5% of the African population have access to assisted conception services [3]. This is further compounded by the high tubal factor infertility requiring in-vitro fertilization. Assisted conception requires significant investment in manpower and infrastructure, the cost of which is borne by the patients seeking care. Invariably, assisted conception is strenuous, time consuming, expensive, and often inaccessible to the financially vulnerable. Out-of- pocket payment for services is a major limiting factor in developing countries as insurance coverage and government support are lacking. In the absence of financial protection, out-of-pocket payments can ultimately lead to household poverty [5].
Opportunities: Expanding access to Assisted Reproductive Technology in developing countries will alleviate the impact of infertility which has been declared an issue of Public Health importance by the World Health Organization [6]. Embracing low-cost treatment protocols and partnerships via the hub-and-spoke organization design with relevant stakeholders may be the panacea in developing countries, as resources are far from equitable.
Conclusion: A paradigm shifts by government towards prioritizing infertility management against the background of a delicate balance between overpopulation and paucity of resources will provide succor to the financially vulnerable and often forgotten infertile couples.
Keywords: Access, Assisted Reproductive Technology, Developing Country.
Résumé
Contexte: L’infertilité est un fardeau de santé universel avec des conséquences profondes dans les pays à revenu faible ou intermédiaire (PRFI). La prévalence mondiale de l’infertilité se situe entre 8 et 12% avec des valeurs aussi élevées que 32% en Afrique centrale et australe, souvent appelée «ceinture d’infertilité» [1]. Au Nigéria, un taux de prévalence compris entre 20 et 30% a été estimé en raison de la forte prévalence des infections sexuellement transmissibles [2]. Les conséquences de l’absence d’enfant involontaire dans un pays à revenu faible ou intermédiaire peuvent être dévastatrices, entraînant une privation économique et une diminution des frais médicaux [3]. Les croyances et pratiques socioculturelles accordent une grande importance à la procréation dans les pays en développement, mais il existe une forte disparité entre les citadins et les ruraux en ce qui concerne l’accès aux soins de santé [4].
Défi (s): Il existe un besoin non satisfait de procréation assistée en Afrique subsaharienne car les données publiées suggèrent que moins de 1,5% de la population africaine a accès à des services de procréation assistée [3]. Ceci est encore aggravé par l’infertilité tubaire élevée nécessitant une fécondation in vitro. La conception assistée nécessite un investissement important en main-d’œuvre et en infrastructure, dont le coût est supporté par les patients qui recherchent des soins. Invariablement, la conception assistée est ardue, longue, coûteuse et souvent inaccessible aux personnes financièrement vulnérables. Le paiement direct des services est un facteur limitant majeur dans les pays en développement, car la couverture d’assurance et le soutien gouvernemental font défaut. En l’absence de protection financière, les paiements directs peuvent en fin de compte conduire à la pauvreté des ménages [5].Opportunités: L’élargissement de l’accès aux technologies de procréation assistée dans les pays en développement atténuera l’impact de l’infertilité, qui a été déclarée problème de santé publique par l’Organisation mondiale de la santé [6]. Adopter des protocoles de traitement à faible coût et des partenariats via la conception d’organisation en étoile avec les parties prenantes concernées peut être la panacée dans les pays en développement, car les ressources sont loin d’être équitables.
Conclusion: Un changement de paradigme du gouvernement vers la priorité à la gestion de l’infertilité dans le contexte d’un équilibre délicat entre la surpopulation et la rareté des ressources apportera une aide aux couples infertiles financièrement vulnérables et souvent oubliés.
Mots clés: Accès, technologie de procréation assistée, pays en développement.
Correspondence: Dr G.O. Obajimi, Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan, Ibadan, Nigeria. E-mail: gbolahanobajimi@gmail.com
References
Inhorn MC. Global infertility and the globalization of new reproductive technologies: illustrations from Egypt. Soc Sci Med. 2003 May;56(9):1837-1851.
Okonofua FE. The case against new reproductive technologies in developing countries. Br J Obstet Gynaecol. 1996 Oct;103(10):957-962.
Ombelet W and Onofre J. IVF in Africa: what is it all about? Facts Views Vis Obgyn. 2019 Mar;11(1):65-76.
Sharma S, Mittal S and Aggarwal P. Management of infertility in low resource countries. BJOG. 2009 Oct;116 Suppl 1:77-83.
Xu K, Evans DB, Carrin G, et al. Protecting households from catastrophic health spending. Health Aff (Millwood). 2007 Jul-Aug;26(4):972-983.
Boivin J, Bunting L, Collins JA and Nygren KG. International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care. Hum Reprod. 2007 Jun;22(6):1506-1512.
Inhorn MC and Patrizio P. Infertility around the globe: new thinking on gender, reproductive technologies and global movements in the 21st century. Hum Reprod Update. 2015 Jul-Aug;21(4):411-426.
Njagi P, Groot W, Arsenijevic J, et al. Economic costs of infertility care for patients in low-income and middle-income countries: a systematic review protocol. BMJ Open. 2020 Nov 10;10 (11):e042951. doi: 10.1136/bmjopen-2020-042951.
Chimbatata, N. and Malimba, C. Infertility in Sub-Saharan Africa: A Woman’s Issue for How Long? A Qualitative Review of Literature. Open Journal of Social Sciences 2016; (4): 96-102. doi: 10.4236/jss.2016.48012.
Omoaregba JO, James BO, Lawani AO, Morakinyo O and Olotu OS. Psychosocial characteristics of female infertility in a tertiary health institution in Nigeria. Ann Afr Med. 2011 Jan-Mar;10(1):19-24.
Cates W, Farley TMM and Row PJ. Worldwide patterns of infertility: is Africa different? Lancet 1985; 2:596-568
Szamatowicz M. Assisted reproductive technology in reproductive medicine - possibilities and limitations. Ginekol Pol. 2016;87(12):820-823.
Ndegwa SW. Affordable ART in Kenya: The only hope for involuntary childlessness. Facts Views Vis Obgyn. 2016 Jun 27;8(2):128-130.
Van Balen F and Bos HM. The social and cultural consequences of being childless in poor-resource areas. Facts Views Vis Obgyn. 2009;1(2):106-121.
Ombelet W. The Walking Egg Project: Universal access to infertility care - from dream to reality. Facts Views Vis Obgyn. 2013;5(2):161-175.
Fauser BC, Bouchard P, Coelingh Bennink HJ, et al. Alternative approaches in IVF. Hum Reprod Update. 2002 Jan-Feb;8(1):1-9.
Brezina PR and Zhao Y. The ethical, legal, and social issues impacted by modern assisted reproductive technologies. Obstet Gynecol Int. 2012;2012:686253. doi: 10.1155/2012/686253.
Fadare JO and Adeniyi AA. Ethical issues in newer assisted reproductive technologies: A view from Nigeria. Niger J Clin Pract. 2015 Dec; 18 Suppl: S57-61. doi: 10.4103/1119-3077.170823.
Kyei JM, Manu A, Kotoh AM, Meherali S and Ankomah A. Challenges experienced by clients undergoing assisted reproductive technology in Ghana: An exploratory descriptive study. Int J Gynaecol Obstet. 2020 Jun;149(3):326-332.
Tangwa GB. ART and African sociocultural practices: worldview, belief and value systems with particular reference to francophone Africa. In: Vayena E, Rowe PJ, Grifûn PD (eds). Current Practices and Controversies in Assisted Reproduction. Geneva, Switzerland: World Health Organization, 2002,55–59.
Ombelet W, Cooke I, Dyer S, Serour G and Devroey P. Infertility and the provision of infertility medical services in developing countries. Hum Reprod Update. 2008 Nov-Dec;14(6):605-621.
Dyer S, Archary P, Potgieter L, et al. African Network and Registry for Assisted Reproductive Technology. Assisted reproductive technology in Africa: a 5-year trend analysis from the African Network and Registry for ART. Reprod Biomed Online. 2020 Oct;41(4):604-615.
Brezina PR and Zhao Y. The ethical, legal, and social issues impacted by modern assisted reproductive technologies. Obstet Gynecol Int 2012; 2012:686253
Omokanye LO, Olatinwo AW, Durowade KA, et al. Pregnancy outcomes following assisted reproduction technologies for infertile women at a public health institution in Nigeria. Trop J Health Sci 2015; 22:25-27.
Elrod, J.K. and Fortenberry, J.L. The hub-and-spoke organization design: an avenue for serving patients well. BMC Health Serv Res 17, 457 (2017). https://doi.org/10.1186/s12913-017-2341-x
Lin M, Kawasaki A. Where to enter in hub-spoke airline networks. Pap Reg Sci. 2012;91(2):419–436.
Skipper J, Cunningham W, Boone C and Hill R. Managing hub and spoke networks: a military case comparing time and cost. Journal of Global Business and Technology. 2016;12(1):33–47.
Jinadu FO, Agunloye AM, Adeyomoye AA, Adekoya AO and Obajimi GO. Public–private partnerships in Nigerian teaching hospitals: Potential and challenges. West Afr J Radiol 2020;27:143-149