by: Dr. Silke Dyer
Infertility in South Africa is common and associated with many negative psycho-social consequences often resulting in profound suffering of those affected. Despite this, access to quality infertility care is difficult for the majority of infertile patients living in South Africa. Comprehensive infertility care including assisted reproductive techniques (ART) is predominantly offered through the private sector in urban centres, with very limited or no insurance benefits offered by private medical aids. These facilities are largely inaccessible to rural and poorer patients.
The public health sector is structured into 3 levels of care: primary care provided by professional nurses and non-specialist doctors, secondary care provided by non-specialists and specialist, and tertiary care provided by specialist and sub-specialists. Primary care facilities are essentially walk in services while level 2 and 3 services may be accessed in an emergency or by referral. To date, many primary care facilities largely neglect infertile patients as these are either not considered a priority within very busy health services or because service providers are uninformed about the management required. A similar scenario is likely to exist at many level 2 services although the infrastructure for basic investigations and interventions should in principle be available and is indeed utilized by some. At level 3 facilities for infertility care are usually available but with considerable regional variations in scope, quality and practice. ART is only offered in very few public-academic centres and often reliant on patient co-payment.
A variety of strategies are currently being followed to improve access to quality infertility care. Role players include, among others, national and provincial Departments of Health, SASREG (The Southern African Society of Reproductive Medicine and Gynaecological Endoscopy), the FIGO Committee for Reproductive Medicine, Medical AIDS, as well as researchers and doctors.
Under the leadership of SASREG the South African Register for ART was formed, and the 1st report on ART conducted during 2009 is currently in press. This data is critical to inform all stake holders to what (limited) extent the need for ART is currently met in our country, and with what efficiency. Together with future data on safety, this information will be important, for example, in negotiations with medical aids on infertility-related benefits. Accreditation of ART clinics through peer-review by SASREG is a further move towards consistent quality care and similarly relevant to discussions regarding 3rd party funding of infertility treatment.
In the public sector documents have been drafted at both national and provincial level regarding more comprehensive provision of infertility care. While these documents reflect political willingness, they still by and large require practical translation into better care to the individual patient. Important barriers include lack of skills, especially at primary care, and limited resources paralleled by many competing health needs including HIV/AIDS, maternal morbidity and cervical cancer to name but a few. In order to improve primary providers’ knowledge and skills in infertility, as well as generally in gynaecology, clinicians of the University of Cape Town (UCT) have published a book on ‘Well Women’ (accessible at www.ebwhealthcare.com). This book is part of a self-learning series for nurses and doctors, provides information in an easy to read logical progression of ‘knowledge bites’, and is accessible at very low cost or free on-line. Presenting information on infertility management together with information on family planning (and other gynaecological conditions) educates service providers that, in the words of Mahmoud Fathalla, “Family planning must also mean planning for a family”; and provides a practical tool how to go about it. Efforts are currently directed at making this book available to primary care doctors and nurses in the Cape Town Metropol. If successful and of proven benefit further roll-out is hoped to follow.
Lastly, discussions of resource allocation should be informed by good data on burden of disease. Such data is currently lacking with regard to infertility in South Africa. To address this information gap UCT researchers are currently conducting a large household survey in two poor African communities in Cape Town on infertility prevalence and infertility-related quality of life. Related data on disability are collected as part of the same survey. It is anticipated that the results of this research project will help to inform debates on resource allocation for infertility in future.
Although these various activities are neither perfectly aligned nor coordinated, they do have a common goal, namely to make quality infertility care more available and more accessible to women and men living in South Africa. As such they fall in line with Millennium Development Goal 5b: to achieve universal access to reproductive health.