Devlin Nancy, Parkin David
Department of Economics, City University, Northampton Square, London EC1V 0HB, UK.
Hum Fertil (Camb). 2003 May;6 Suppl 1:S2-6. doi: 10.1080/1464770312331369153.
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.
在大多数发达经济体中，辅助生殖技术（ARTs），尤其是体外受精（IVF）的适当资金水平和来源一直存在争议。国际上生育服务的资金特点是公共（或其他第三方）资金投入低，比大多数其他医疗服务更依赖使用者付费，且资金投入和服务提供存在差异。本文描述了不孕症作为一种病症及其治疗的特点，这些特点被用作将其排除在其他全面的医疗服务覆盖范围之外的理由。讨论了这些特点给利用经济评估为资源分配提供信息带来的挑战。大多数经济评估都集中在替代不孕症治疗方法的成本效益上。这些评估提供了重要信息，但没有涉及关键问题：鉴于ARTs涉及牺牲其他领域的健康改善，那么对ARTs的适当资金分配是多少？成本效用分析——大多数负责做出此类决策的机构（包括英国国家临床优化研究所）首选的经济评估方法——并不适合处理ARTs产生的效益。有其他方法可用，但要求决策者权衡非常不同类型的证据。证明为ARTs的效益支付意愿可用于支持公共决策，但相反，这也意味着有支付能力的人将在私人市场支付费用。最终，关于是否将ARTs纳入集体资助的医疗系统的决策，可能同样取决于对公平获取的判断以及性价比。鉴于此，对IVF的公共资金投入应伴随着制定商定的标准，对潜在接受者进行优先排序，以确保治疗针对最有效的人群，并且获取途径一致且公平。
