Singapore should beware of the pitfalls of co-funding private IVF treatment

Angelica Cheng

Active Member

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 screening, endometrial (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?
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新加坡正面临着一个人口的重要转折点,因为该国2023年的总生育率(TFR)首次降至每名妇女1.0个孩子以下, 当前值为0.97, 超过了2022年每名妇女1.04个孩子的历史最低点。

连续两年创下纪录的低生育率无疑引起了新加坡政府决策者的极大警觉,他们现在认为这对于这个小岛城邦未来的经济增长和国家生存构成了威胁。 可能需要采取严厉措施来缓解这一可怕而绝望的局面。

事实上,最近的一篇新闻报道称, 新加坡国会正在讨论将目前对公立医院试管婴儿治疗的补贴扩大到私人生育诊所。

目前, 40岁以下的新加坡女性可以从政府获得高达75%的共同资助,用于最多三个新鲜和三个冷冻试管婴儿周期 。







首先, 私营医疗机构的最终目标是实现利润最大化,因为它们对股东负责,而公立医院则对政府和公民负责 。


因此, 为什么不利用相同数量的公共资金来升级和扩大公立医院的试管婴儿设施呢? 例如,通过雇用更多的生殖医学专科医生和其他与试管婴儿相关的医务人员,以及购买更多设备以提高试管婴儿实验室处理更多病例的能力。

其次, 在分配纳税人的钱来补贴该国公民的医疗保健时,也存在谨慎和公平的问题。 如果在私人医疗机构中,试管婴儿治疗被单独列为补贴对象,那么在私人医疗机构中,对中风、癌症、心脏病和肾病等危及生命和使人衰弱的疾病的补贴又该如何呢?与既不健康也不能挽救生命的体外受精治疗相比,这种致命的、毁灭性的疾病难道不应该得到更多的公共资金吗?


因此 ,应授权对私人试管婴儿诊所的业绩记录进行严格的年度审计,以使其有资格获得来自公共资金的此类补贴。



通过要求试管婴儿成功率达到一定标准才能获得补贴,可以有效防止私人试管婴儿诊所利用那些试管婴儿成功率较低的患者的绝望情绪。 例如,由于过早绝经或癌症化疗导致卵巢储备严重减少的患者,或需要手术从睾丸中提取未成熟精子的严重男性伴侣不育症患者。


除了定期审核私人试管婴儿诊所的试管婴儿成功率外,还必须严格监管补贴前试管婴儿治疗的总价,以确保政府共同资助不会成为私人试管婴儿诊所进一步提高医疗费用以最大限度地提高盈利能力的动力,因为患者现在通过这种补贴支付的费用更少。 价格控制的目标必须是确保患者和政府的“物有所值”。


英国人类受精和胚胎学管理局(HFEA)保留了一个有争议和可疑的体外受精治疗附加程序的黑名单 ,这些程序是可选的和非必要的。





此外, 还有成本效益的合理化的问题 ,即政府对试管婴儿的补贴到底能否缓解新加坡低生育率和人口迅速老龄化的人口问题。来自其他生育率低和试管婴儿诊所系统发达的富裕和发达国家的统计数据可能会提供线索。


因此, 试管婴儿充其量不能将出生总数提高10%以上,这很难改善任何一个远远达不到每名妇女生育2.1个孩子的人口替代率的国家的人口结构。

尽管如此,也许可以认为将共同资助扩大到私人试管婴儿治疗实际上具有象征性的意义,作为新加坡政府的一种姿态,表明他们确实 通过辅助生殖关心和支持无子女夫妇艰难而紧张的育儿之旅 。



如果私人试管婴儿机构的治疗能够得到补贴,可能会导致公共医疗资金的分配优先次序出现不当 ,而对于那些威胁生命的疾病可能没有得到足够紧急的治疗,因为试管婴儿治疗预计不会显著改善国家的低出生率。
Committee of Supply 2024 debate, Day 5: Louis Ng on extending IVF subsidies to private clinics, providing subsidies for fertility testing and ensuring nurses have sufficient rest
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