The analyses raised a few trends among Spanish ART patients’ behavior. First, patients who were treated exclusively in public clinics or who combined treatment in both public and private had, on average and throughout the treatment, a lower cumulative incidence of becoming pregnant compared with patients who were treated exclusively in private clinics (Fig. 1). Second, women with a larger income and higher education levels had a higher likelihood of approaching ART services in private clinics and a lower tendency of approaching public clinics. Third, women of lower socioeconomic backgrounds had a lower likelihood of accessing ART services in general. Additionally, our model quantifies the estimated effect of income on the probability of accessing ART in private or public clinics or having no access. Finally, single women had a lower probability of being treated in public clinics and accessing ART services in general since they were excluded from public services in many autonomous communities [36].
Concerning the gap in the cumulative incidence of getting pregnant (model 1.2, Fig. 1). Some patients exercise their right for public coverage first, whereas others begin treatment in a private clinic while remaining on the public clinic’s waiting list [13, 48]. However, public coverage is limited to three cycles and the average waiting time between cycles is around one year. We can conclude that, following 36 months, most patients are treated in private clinics, although the gap remains constant. Based on the National Activity Registry by the Spanish Fertility Society (SEF) and as analyzed by Romero et al. [48], we may assume that the quality of care and success rates in public ART clinics in Spain does not fall from the sector’s standards [48, 52]. It is difficult to determine that private clinics produce a significantly better outcome [13], as they usually handle better prognosis. Moreover, they can treat “good” patients with their own eggs and patients of poor embryonic development or low ovarian reserve with donor eggs.
Hence, we identify three factors that may explain the gap in the cumulative incidence of success. First, long waiting periods in public clinics [40, 25] prolong the treatment and delay success. Second, a patient older than 35 years with a poor prognosis would more commonly be offered to repeat another cycle, using her own eggs, while private centers offer egg donation earlier. Third, some patients would stop treatment after exhausting their right for three subsidized cycles.
As we may learn from the Biprobit models, Spanish patients are aware of public ART disadvantages and perceive better odds within private clinics. Despite the availability of three publicly covered cycles, 41% of the respondent (55% of the patients) accessed ART exclusively in private clinics. At the onset of treatment, their mean age was 35.5, within the eligible age for public care (we have no information about marital status at treatment onset). The tendency to approach private care is due to long waiting lists and other preferences [13, 54]. Only 12% of the respondents combined both types of services. Additionally, 21% accessed only public clinics; of them, 58% did not get pregnant and stopped treatment.
Also, 26% of the respondents required ART but did not access any service. The main barriers are clearly financial, while 21% reported ineligibility for public care, which could be due to advanced age or being single (we do not know their age or status at the time of requiring ART).
Based on these findings, we raise some doubts about the operating principles of public ART services in Spain. The Spanish law 14/2006 on ART is set to provide ART services until 40 years. However, in their current format, public clinics provide an incomplete solution, affected by long waiting lists throughout the treatment, which may interrupt treatments, waste valuable time in their race against aging and could result in reduced outcomes, increased frustration, stress and mistrust [13, 39, 40, 48, 56].
This situation incentivizes most patients, particularly those of higher education and income, to seek services exclusively in private clinics. The dependency on the private sector intensifies ART’s commodification, results in supplier-induced demand, i.e., private centers often rush patients to acquire costly solutions and offer some excessive add-ons [3, 4, 17, 27, 44].
Ideally, public clinics’ capacity should be increased to reduce the gap and meet the law’s intentions. Nevertheless, bearing in mind the limited resources and different priorities in public healthcare, it is arguably suggested that Spanish policymakers would analyze resource allocation optimization in ART, focusing on public clinics’ efficacy by reconsidering both the age limit and the number of cycles. Perhaps, reducing the age of eligibility to public care to below 40 years (for women) may enable faster provision for younger, more disadvantaged patients who suffer from pre-existing rather than age-related infertility and tend to have fewer financial resources [19]. It might also enable providing more than three cycles, which may not be sufficient to fulfill ART potential.
More hypothetically, by funding three ART cycles up to 40 years, this policy signals two wrong messages to the public. First, 40 is still a reasonable age to have a first child and second, three ART cycles should be sufficient. ART registries from various countries, including Spain, illustrate that treatment is becoming less effective after 35 years and that often more cycles are required [14, 53]. Moreover, it has been suggested that public coverage may lead to an increase in average age at first birth and might even negatively affect fertility rates [29, 37]. Therefore, ART’s limitations and risks in advanced maternal age should also be considered, alongside alternatives that may reduce infertility [34] to avoid a social trend of parenthood postponement [35].
Our study has a few limitations, mainly derived from the available information by the SFS and from the fact that the survey was not designed to directly answer our research questions. It enables us to conduct a cross-section analysis since the participants were surveyed only once at a particular moment. More precisely, the SFS provides data about income and marital status at the time of replying and not while attending or requiring services. Conversely, a longitudinal study could provide clearer conclusions. It is reflected mainly by the variation in income and marital status, which may change during a person’s life-course, unlike education levels, which mostly maintain constant. Moreover, the SFS does not report about insurance, waiting periods and the number of children. It reports both employment status and urban status, but we assume that household and personal income already reflect those (and insurance). Additionally, autonomous communities may reflect urban status, as well as distance from clinics.
Finally, we recommend several research directions that can contribute to better understanding and policy planning. First, it would be interesting from a public perspective to evaluate public ART provision in Spain by operational analysis to help find a more effective and efficient allocation of the limited resources. Second, a model of (partially) public funding and private provision (such as the “PADI” plan for dental health program for children [10]) should be evaluated and considered as an alternative, despite that such model may create conflict of interests between private enterprises and policy makers, lead to supplier-induced demand, and may enhance the principal-agent problem. Fourth, considering that ART in private clinics may be costly, conducting a survey or a series of interviews could raise important insight into young couples’ ongoing financial burden. Finally, about the SFS (conducted in 1999 and 2008), conducting a public fertility survey requires a significant public investment and aims to provide potential researchers with valuable data. When the opportunity to conduct a subsequent survey emerges, its designers should elaborate on an open discussion with researchers who may find interest in exploring the collected data. Sharing experiences and common interests may assist in directing the survey towards researchers’ needs.