Local Government Initiatives: A Comprehensive Analysis of Infertility Diagnostic and Treatment Programs in Poland (2009–2020)

Introduction

Infertility is treated by the World Health Organization as a disease of the female or male reproductive system that makes it impossible to get pregnant after a year or more of regular sexual intercourse without the use of contraceptives [1]. The causes of infertility are very complex. Various situations cause hormonal disorders, which can lead to anovulatory cycles in women and deterioration of semen biological parameters in men. In 20–30% of women, the cause is occlusion of the fallopian tubes [2,3]. In high- and middle-income countries, infertility is the leading cause of childlessness. It affects 10–15% of couples of reproductive age; globally, it affects 60–80 million couples [4].

Infertility often creates complicated and multifaceted psychological problems for people trying to conceive [5–7]. It is also a factor affecting the demographic condition of societies and countries, and thus the economic situation, and indirectly the well-being of the entire society [8].

The extent of the occurrence of infertility in Poland is not precisely known, as there are no exhaustive studies in this area; it is assumed that it is similar to the situation in high-income countries and may affect 1.0–1.5 million Polish couples, which is 15–20% of the population of reproductive age [9].

In Poland, since 2013, there has been a natural decline in the population resulting from a low number of births, with a simultaneous increase in the number of deaths resulting from an increase in the number and percentage of elderly people [10]. It should be added, however, that the latest data did not yet include changes related to the influx of refugees, as well as all deaths resulting from the COVID-19 pandemic.

Worldwide, there has also been a decline in fertility since the early 1960s. The governments of three-quarters of the UN member countries have active fertility policies [11]. In Poland, the issues of reproductive health were implemented based on the operational objective of the National Health Program for 2016–2020. However, these issues were not included in the next edition of the Program for 2021–2025, despite social protests [12]. The National Health Program is a document that sets priorities for public health activities. On its basis, it is possible to implement projects aimed at achieving the goals set out therein.

It should be emphasized that no nationwide program aimed at the diagnosis and treatment of infertility was implemented in Poland before 2013. The first nationwide program implemented from July 1, 2013 to June 30, 2016 by the Minister of Health was “Infertility Treatment Program by In vitro Fertilization for the years 2013–2016”, under which in vitro fertilization treatment was subsidized from public funds. From September 1, 2016, this program was replaced by the “Comprehensive Reproductive Health Care Program in Poland”, which is to be implemented until the end of 2024. Despite such a title, the government program for comprehensive reproductive health protection does not provide for public funding of infertility treatment by in vitro fertilization. Consequently, this method has been treated by the Polish government as a private matter of couples wishing to have children. The situation changed at the end of 2023, when, after the parliamentary elections and change of government in Poland, an act was announced and adopted providing for the implementation of a program including the in vitro fertilization procedure starting in mid-2024. The details of the program are not known, apart from the fact that approximately EUR 115 million is to be allocated for its implementation each year. Currently (April 2024), treatment of infertility by in vitro fertilization is possible, but not covered by health insurance. Infertility treatment using other methods is included in the list of guaranteed benefits (financed from public funds under health insurance) as part of outpatient and hospital treatment (eg, artificial insemination). In vitro fertilization is considered effective in the treatment of infertility [1,8,13,14]. An important element preceding the implementation of in vitro fertilization is proper diagnosis of the causes of infertility and consideration of the use of other, cheaper, and less invasive treatment methods at an earlier stage [1,15]. From the point of view of patients and the state, it is important to ensure the possibility of financing all available and effective infertility treatment methods, especially given the demographic situation in Poland. approximately 305 000 children were born in Poland in 2022, and approximately 272 000 children were born in 2023 the lowest number recorded in the entire period after World War II [16].

Due to the uncertain financing of procedures at the central level, over the years local government units have been actively involved in implementation of infertility treatment programs.

Until 2015, in Poland, local governments could implement activities through health programs. Such programs could also be implemented centrally by the Minister of Health and the payer in Poland, which is the National Health Fund. After 2015, health policy programs were introduced into the system, which could only be implemented by local governments and the Minister of Health. Health programs from that moment were reserved exclusively for the National Health Fund. There are 3 levels of local governments in Poland: self-governments of the voivodeships (a unit of administrative division of the highest level); second-level local governments, which cover a part of the voivodship (poviats and cities with poviat rights), and basic units of local government, which are communes (there are 3 types of communes in Poland: urban, rural, and urban-rural). Interpreting the currently functioning regulations, cities with poviat rights are classified as communes that perform tasks assigned to both communes and poviats. In Poland, as of January 1, 2024, there were 16 voivodeships, 314 poviats, 66 cities with poviat rights and 2477 communes (302 urban communes, 711 urban-rural communes, and 1464 rural communes) [17]. The above types of local government units are arranged from the largest (voivodeships) to the smallest (rural communes). Within each voivodeship there are several/several dozen poviats, as well as several cities with poviat rights (the largest cities in Poland). In turn, communes operate within a poviat. Each local government unit has different tasks specified in Polish law. At the same time, all of them have the opportunity to implement health policy programs for their residents.

For many couples, due to limited financial and organizational possibilities, programs implemented (and thus also financed) by local governments were of fundamental importance in the treatment of infertility by in vitro fertilization. These programs constitute an optional form of public health.

The objective of this study was to present and analyze data about programs for the diagnosis and treatment of infertility that were developed, implemented, and financed by local governments at all levels in Poland in the years 2009–2020, in terms of the types of interventions undertaken, the number of participants, and costs.

Material and Methods

The study was conducted based on the analysis of existing data. The data were obtained from the Minister of Health under the provisions of the Act on Access to Public Information after we sent an electronic request to receive it [18]. Thanks to this, we gained access to reports on all public health tasks undertaken by local government units from 2009 to 2020.

The presentation of the reproductive health programs implemented in 2009–2015 was based on the collective information provided to the Minister of Health by the voivodes on the programs implemented by local governments. Voivodes are representatives of the Polish government in individual voivodeships. One of the statutory tasks assigned to voivodes is to collect, analyze, and provide the Minister of Health with data on public health tasks carried out by local governments. From the aggregated information on the programs implemented, we extracted data on programs run by individual levels of local governments and concerning the diagnostics and treatment of infertility. The process of reporting on programs implemented by local governments until the end of 2015 was regulated by the Act of August 27, 2004 on health care services financed from public funds. The reporting rules were changed starting from 2016.

To present information on programs implemented in 2016–2020, we used data from annual information on public health tasks carried out by local governments, prepared by voivodes, and submitted to the Minister of Health. The reporting process of local governments, starting from 2016, is regulated by the Regulation of the Minister of Health of December 21, 2016 on annual information on completed or undertaken tasks in the field of public health. From the aggregated information on activities in the field of public health, data on programs conducted by individual levels of local governments and concerning the diagnosis and treatment of infertility was extracted.

The reports referred to above contain information on the name of the health policy programs implemented, the implementing entity, the population covered by the program (age range indicated independently by the local government), and the total cost.

The basis for the selection and analysis of the programs was finding one of the following phrases in the title or description of the implemented activities: procreation; reproductive health; fertility; infertility; childlessness; infertility diagnostics; artificial insemination; in vitro; in vitro fertilization; insemination; NaProTechnology.

In case of doubts regarding the correctness of the entered data, the local government was contacted directly by e-mail to clarify and obtain verified information.

In terms of data on infertility diagnosis and treatment programs, 3 categories were distinguished: programs aimed mainly at infertility diagnosis; programs including co-financing for in vitro fertilization; and programs aimed at natural methods of procreation (NPT, Natural Procreative Technology).

The above categories include information on the number of programs and people covered by the programs (in total and broken down by particular types of local governments), as well as data on the costs incurred for the implementation of the programs (in EUR).

The primary cost of activities was reported by local governments in Polish currency (PLN). To present data in a more understandable way for recipients from countries other than Poland the costs were converted into EUR. For this purpose, the average value of the euro exchange rate from 2012–2020 (the period in which at least 1 program was implemented) was checked, which was PLN 4.26.

In the annual reports on public health tasks carried out by local governments, the number of people (women and men together) covered by the measures was usually provided. In some cases, however, the number of couples was given (this was mainly the case with in vitro fertilization programs). In their case, the number of couples was doubled to obtain the number of people subjected to the procedures. Therefore, all results in our article represent the number of people subjected to the procedures, not the number of couples.

Excel was used to make the calculations, in which the values of the analyzed parameters (number of participants and program costs) were summed up.

Results

As part of infertility diagnosis and treatment programs, local governments implemented activities directly related to infertility diagnosis and treatment. Educational activities were conducted for participants of the program on reproductive health, and a healthy lifestyle for women and men was promoted. In the vast majority of programs, information activities were undertaken by distributing posters, brochures and educational leaflets and conducting social and information campaigns, radio broadcasts, TV spots, and activities in social media. Twenty-three local governments of various levels participated in the implementation of these programs, including 5 communes, 13 cities with poviat rights, 1 poviat, and 4 voivodships.

Data on the number of programs and people covered by infertility diagnosis and treatment programs in the years 2009–2020 are presented in Table 1. Some of the programs were implemented for many years. However, due to the annual mode of reporting activities, the table below shows the number of programs implemented in a given year, regardless of whether they were programs planned for 1 year or many years.

In the years 2009–2011, no local government implemented programs concerning infertility diagnosis and treatment. Programs of this type began to be implemented in 2012. Since 2017, a significant increase in the number of implemented programs and the number of people participating in them has been noticeable. A total of 22 379 people were covered by infertility diagnostics and treatment programs in the years 2012–2020. The largest number of people participated in programs implemented in 2020. In the case of the program implemented in 2016, the report does not specify the number of participants.

Data on the number of people covered by infertility treatment programs, broken down by individual types of local governments, are presented, considering the number of people participating in infertility diagnosis, in vitro fertilization, and NPT programs (Table 2).

By far the largest group of people were covered by programs implemented by cities with poviat rights (90% of people participating in all programs). Cities with poviat rights implemented activities aimed at infertility diagnosis and in vitro fertilization, but did not implement NPT programs. The smallest number of people participated in programs implemented by communes (114) and poviats (100). Communes, starting from 2018, and poviats, starting from 2019, financed the in vitro procedure under the programs. They did not finance infertility diagnostics and NPT programs. NPT programs were financed by only 2 voivodship governments. In vitro fertilization was financed in 3 voivodeships.

Data on the costs of infertility treatment programs are presented, broken down by individual types of local governments, considering the number of people participating in infertility diagnosis, in vitro fertilization, and NPT programs (Table 3).

The cost of all programs implemented in 2012–2020 was EUR 10 785 282. The amounts spent varied considerably from year to year. The smallest amount was spent on this purpose in 2012 (EUR 8451), and the largest was in 2020 (EUR 4 116 535). Cities with poviat rights allocated the most to the programs, and their expenditure accounted for over 89% of all costs incurred. Slightly more than 10% of all costs of the programs were incurred by voivodeship authorities, while communes and poviats spent a total of less than 1% for this purpose. From the analysis of the programs, it can be concluded that the maximum amount of co-financing for a couple for one in vitro fertilization procedure was usually about EUR 1174.

Discussion

Low fertility rates constitute a growing global problem. The decline began in the early 1960s and continues today. In 2019, half of the people in the world lived in countries where the birth rate did not ensure the level of generational replacement [19]. Most countries in the world have a population policy aimed at increasing or, less frequently, lowering fertility [11]. However, recent studies of global infertility trends show an improvement in infertility rates in countries with a high and middle level of national income [20]. It is believed that one of the reasons is the sufficient availability of assisted reproductive technology [21]. The opposite phenomena are observed in countries with a low level of national income. Here, one of the causative factors is poor access to modern infertility diagnosis and financial obstacles among the low-income population. Such people are deprived of the opportunity to achieve their reproductive goals, which may be considered a violation of human rights [22,23].

Poland is also one of the countries with low fertility rate and birth rates that do not ensure generational replacement. In Poland, the need to take and continue measures to protect reproductive health was reflected in strategic documents for public health, namely the National Health Program for 2007–2015 and the Program for 2016–2020. Implementation of the guidelines set out in the National Health Programs rests with the government administration and local governments. In this regard, in the years 2013–2016, the Government Program for Infertility Treatment by In vitro Fertilization was implemented. At the end of the program (June 30, 2016), 22 623 couples were registered, and at the end of 2016, a total of 6706 live births were recorded (including 2581 in 2016). The ratio of the number of clinical pregnancies to the number of transfers was approximately 32% [24]. Therefore, there was a great demand for this type of service [25]. After the change of power in Poland in 2015, despite social protests, its implementation was not extended for the next years, and the burden of financing an in vitro procedure was treated by the Polish government as a private matter of couples wishing to have children. The “Comprehensive Reproductive Health Care Program in Poland” has been implemented since 2016, and it includes patient education, infertility diagnosis (duplicating most of the services already available in the Polish system), pharmacotherapy, and surgical treatment, but did not finance in vitro fertilization. According to available data, by the end of 2019, 5727 couples registered for the program, and 2649 couples completed the diagnostic stage. Only 1155 couples were referred for further infertility treatment. According to data from 2019, because of activities undertaken in 2019, 294 pregnancies were recorded (status as of April 2019) [26]. At the same time, reporting the number of pregnancies was not obligatory, which is a significant limitation of the program itself and limits interpreting the data. There are also no data on the number of children born.

It seems that part of the cost of financing in vitro fertilization was taken over by local governments. Starting from 2016, an increase in the number of infertility diagnosis and treatment programs was observed. There is no doubt that local governments that developed, implemented, and financed the programs undertook to implement the guidelines set out in strategic documents. However, because over 99% of communes and poviats, 80% of cities with poviat rights, and 75% of voivodships did not implement infertility diagnosis and treatment programs in the period under review, the involvement of local governments in the implementation of this objective of the National Health Program was definitely insufficient. Additionally, apart from financing in vitro procedures in voivodeships, it has a local character. Local governments finance activities only for the residents of a given local government community, most often using the criteria of place of residence and tax payment, which causes inequalities in access to these benefits.

In vitro fertilization programs were carried out mainly in large cities, which are cities with poviat rights (eg, Warsaw, Poznań, Wrocław, Gdańsk, Łódź, Słupsk). Therefore, this means that the residents of poviats and communes had no chance to obtain co-financing and had to finance treatment from their own resources. An exception may apply to residents of the regions where the voivodeship government finances in vitro fertilization. However, considering the number of people participating in voivodeship programs (1512), this is of marginal importance.

For years, it has been proposed to consider reintroducing financing of in vitro fertilization at the central level. There were 2 ways to do this. Firstly, in vitro fertilization could be considered a guaranteed benefit, which in turn will mean financing by the National Health Fund. Secondly, it was possible to introduce, following the example of the program implemented in 2013–2016, a government health policy program providing for financing of in vitro fertilization. Ultimately, the second option was chosen and the government health policy program will be implemented from mid-April [27].

It is worth emphasizing that in the analyzed period (until 2020) in many other European countries (eg, Scandinavian countries, France, Portugal, the Netherlands, Croatia) public financing of various infertility treatment methods, including in vitro fertilization, has been in place for a long time [28]. In Poland, as mentioned above, the situation was different, which is reflected in the data from the European Atlas of Fertility Treatment Policies. According to this study, in 2021, Poland had one of the worst rates of access to infertility treatment in Europe (41st place out of 44 countries analyzed) [29].

A limitation of the study is the lack of certainty regarding the correctness of the data provided by local governments in annual reports. The system of reporting activities undertaken in public health is obligatory in Poland. At the same time, verification of the correctness of the reported data by the voivode and the Minister of Health may be considered insufficient (including considering that some local governments reported the number of couples, not the number of individuals covered by the programs). Taking these limitations into account, we tried to minimize the risk of error by randomly checking the correctness of the data, visiting the websites of local governments where information about the implementation of programs was sometimes published, and contacting them by phone to confirm the correctness of the information. Another limitation of this study is the inability to analyze detailed data from local government programs regarding the qualification of patients for particular infertility treatment methods and the effectiveness of the activities undertaken, including the number of children born (the public health reports we relied on do not include such data). In the future, however, it would be worth trying to analyze the effectiveness of infertility treatment programs (including an analysis of the number of pregnancies and children born) by asking local governments to provide such data.

Conclusions

In Poland, as part of the guaranteed benefits financed from public health insurance, in the field of infertility, it is mainly possible to diagnose the causes of infertility and take advantage of a simple method of assisted reproduction – artificial insemination.

A small number of local governments in Poland undertook actions aimed at co-financing in vitro procedures. Financing by local governments, mainly cities with poviat rights, of in vitro fertilization was local, which deepened inequalities in access to this procedure.

However, following a recent announcement by the Polish government, a new program, planned for implementation in mid-2024, will potentially improve access to infertility care by providing coverage for in vitro fertilization.