February 29, 2024

Singapore should beware of the pitfalls of subsidizing private IVF treatment

Singapore faces a demographic milestone as its total fertility rate (TFR) for 2023 has for the first time dropped below one to 0.97 births per woman, surpassing the previous year’s record low of 1.04 births per woman in 2022. Two consecutive years of record low birthrates would certainly cause much alarm to Singapore government policymakers, who would now view this as an existential threat to the future economic growth and national survival of this tiny island city-state. Drastic measures will likely be called for to mitigate such a dire and desperate situation. Indeed, a recent news article reported that the Singapore parliament discussed extending current subsidies of IVF treatment in public hospitals to private fertility clinics.  

Currently, Singaporean women below 40 years of age can receive up to 75% in co-funding from the Government for up to three fresh and three frozen IVF cycles. Women above 40 years old are eligible to be co-funded for up to two IVF cycles, provided that they had attempted at least one IVF or IUI (Intrauterine Insemination) cycle before the age of 40.

Nevertheless, there is currently a heavy patient load at public IVF clinics, with many patients frustrated by long waits. Because female fertility declines sharply with age, particularly for older women above their mid-30s, there are deep concerns that the long waiting times may negatively impact patients’ IVF success rates. Hence the call for extending Government subsidies to private IVF clinics to reduce waiting times.

The Singapore Government should beware of the pitfalls of such a move.

Most obviously, the ultimate aim of private healthcare entities is to maximize profit as they are beholden to their shareholders to do so, whereas public hospitals are held accountable to the government and citizens. Hence if public funds were used to subsidize private IVF treatment, a substantial fraction of taxpayers’ money will ultimately end up as shareholders’ profits, rather than being re-invested back into government healthcare facilities to benefit the public at large. 

Hence the pertinent question that arises is why not utilize that same amount of public funds intended for subsidizing private IVF treatment, to instead upgrade and expand IVF facilities at public hospitals? For example, by hiring more fertility specialist doctors and other IVF-related medical staff, as well as purchasing more equipment to increase the capacity of IVF laboratories to handle more cases.

Then, there is also the question of prudence and equitability in allocating taxpayer’s money to subsidize healthcare for the country’s citizens. If IVF treatment is singled out alone for subsidies in private healthcare, how about also subsidizing life-threatening and debilitating diseases such as stroke, cancer, heart and kidney diseases within the private healthcare setting? Would not such deadly and devastating illnesses deserve more priority for public funding as compared to IVF treatment, which is neither health-saving nor lifesaving? 

Nevertheless, in case the Singapore Government eventually decides to extend co-funding to private IVF treatment, such subsidies should be contingent upon individual private IVF clinics demonstrating higher or equal IVF success rates compared to public IVF clinics, to justify spending of taxpayer’s money. Stringent annual audits of the track record of private IVF clinics should thus be mandated to qualify them for such subsidies coming from public coffers.

By requiring an acceptable IVF success rate to qualify for subsidies, this will discourage private IVF clinics from exploiting the desperation of patients with low chances of IVF success. For example, patients with severely diminished ovarian reserves due to premature menopause or cancer chemotherapy, or patients with severe male-partner infertility that require surgical extraction of immature sperm from the testes. This would thus incentivise private fertility clinics to strongly discourage such patients with low chances of success from pursuing conventional IVF treatment, and instead point them directly to more realistic solutions for having a child, such as egg and sperm donation or even adoption.

Besides regularly auditing IVF success rates of private IVF clinics, there must also be stringent regulation of the gross price of IVF treatment before subsidies, to ensure that government co-funding does not serve as an impetus for private IVF clinics to further raise medical fees to maximize profitability, because patients are now paying less with such subsidies. The objective of price control must be to ensure “value for money”, for both patients and the government. 

Yet another issue to beware is that because patients may have some extra cash to spare in subsidized IVF treatment, some doctors may unscrupulously encourage the uptake of ancillary add-on procedures to IVF that may have dubious therapeutic value. The Human Fertilization and Embryology Authority (HFEA) of the UK maintains such a black list of controversial and dubious add-on procedures to IVF treatment that are optional and non-essential.

For example, using time-lapse imaging to help select IVF embryos with the best chance of developing into a baby by using computer algorithms or artificial intelligence, is rated black by the HFEA for improving IVF success rates. This is because moderate/high quality evidence have shown that this add-on procedure does not significantly improve IVF treatment outcomes.

Other add-on treatment procedures are given an even worse “red” rating by the HFEA, which indicates that these may in fact be detrimental to IVF success rates. For example, preimplantation genetic screeningendometrial (womb lining) receptivity testing, and various immunological tests and treatments for fertility.

Then, there is also the cost-benefit rationalization of how much government subsidies of IVF can actually mitigate or overcome Singapore’s demographic problem of low fertility rates and rapidly aging population. Statistical data from other affluent and developed countries with low fertility rates and well-developed system of IVF clinics may possibly give a clue. For example, recent data from Australia showed that 1 in 18 babies are born via IVF, while in Japan about 1 to 11.6 births are attributed to IVF. Hence at best, IVF cannot boost the total number of births by more than 10%, which would hardly improve the demographics of any country that fall far short of the replacement rate of 2.1 births per woman.

Even so, it can perhaps be argued that extending co-funding to private IVF treatment can in fact serve a symbolic purpose, as a gesture by the Singapore government to show that they do care and support childless couples on their difficult and stressful parenthood journey via assisted reproduction. Nevertheless, it can also be counter-argued that the same amount of money could instead be better-spent on improving and subsidizing childcare facilities and preschool education, which would likely elicit more public gratitude from a much larger number of parents. 

Singapore’s Ministry of Health has a public duty and moral imperative to ensure that taxpayer’s money is wisely spent and prudently utilized to meet the relevant public healthcare needs of the country’s citizens. There could be inappropriate prioritization and misallocation of public healthcare funds if IVF treatment is being subsidized in private clinics, while more urgent treatment for life-threatening diseases is not, given that IVF treatment is not expected to significantly improve the country’s low birth-rate. 

The key question is how much value is Singapore getting in return upon spending of its citizen’s tax dollars on subsidizing private IVF treatment? 

Disclaimer: This article represents the views and opinions of Dr Alexis Heng in his own personal capacity and is not connected to any institutions that he is affiliated with.

Alexis Heng