Access to infertility care services towards Universal Health Coverage is a right and not an option

Background: In Morocco, the national health plan 2025 was developed to promote Sexual and Reproductive Health (SRH) services for all. The principal aim was to achieve the Universal Health Coverage of SRH by 2030. For many years, health authorities’ efforts had focused on reducing maternal mortality through a widespread access to antenatal and obstetric care and family planning services. This has resulted in a significant gap between the availability of SRH components, namely obstetric and family planning care, and access to infertility services including Assisted Reproductive Technology (ART). The objective of this study is to answer two important questions. First, why some SRH programs and services are given priority by international and national political leaders while infertility care receives little attention; second, what are the factors that influence this prioritization? Methods: We used Shiffman and Smith’s framework composed of four elements: the strength of the actors involved in the initiative, the power of the ideas they use to represent the health problem, the nature of the political contexts in which they operate and the characteristics of the services. We added a fifth element to the framework, the outcome. We applied this framework to the case of infertility services in Morocco. We conducted a desk review and interviews with actors involved in SRH and infertility care advocates as well as with decision makers involved in implementing Universal Health Coverage (UHC). Results: Our results showed that despite the efforts made by the advocates of infertility care; the enactment in 2019 of a law regulating infertility care services; and the presence of two Assisted Reproductive Technology Units in the public sector, infertility services remain at an early stage of development hampered by multiple challenges. Among others, a lack of political entrepreneurs to ensure a strong leadership; the political windows were often missed; community members lacked consensus on a coherent public positioning of the problem, and advocates’ perception and power of the idea lacked evidence and precise indicators of the problem. Conclusion: To ensure the convergence and alignment of all stakeholders, it is recommended to translate the regulation of infertility into measurable activities with defined human and financial resources, equitable fertility health coverage, and quality fertility care to respond to women and infertile couples’ needs, rights and dignity.

To conduct this study, we adopted Shiffman and Smith framework to assess the health policy priority setting for SRH package including infertility care services [16]. Using this framework, we explored four categories: the strength of the actors involved in the initiative, the power of the ideas they use to portray the issue, the nature of the political contexts in which they operate, and characteristics of the issue itself [17]. We added a fifth additional element to the framework, the outcome. This element helped to identify if the issue under discussion was taken seriously and prioritized by decision-makers, and if it was adopted by higher authorities along with resources available for implementation [17] (Table ​(Table11). Framework for assessing what factors affect national agenda setting, adapted from the Shiffman and Smith framework 1. Policy community cohesion: the degree of coalescence in the network involved with the issue 2. Leadership: the presence of individuals capable of uniting the policy community, acknowledged as strong champions 3. Guiding institutions: effectiveness of organizations or co-ordinating mechanisms 4. Civil society mobilization: the extent to which grassroots organizations are mobilized to support action 1. Internal frame: the degree to which the policy community agrees on the definition of, causes and solutions to, the problem 2. External frame: public portrayals of the issue in ways that resonate with external actors, especially the political leaders who control resources 1. Policy windows: political moments when conditions align favorably for an issue, presenting opportunities for advocates to influence decision makers 2. Global governance structure: the degree to which norms and institutions operating in a sector provide a platform for effective collective action 1. Credible indicators: clear measures that show the severity of the problem, which can be used to monitor progress 2. Severity: the size of the burden relative to others 3. Effective interventions: the extent to which proposed means of addressing the problem is explained, cost effective, backed by scientific evidence, simple to implement and inexpensive This is an exploratory qualitative case study conducted in Morocco. It is based on a desk review to map and analyze documents regarding infertility care integration within Sexual and Reproductive Health Benefits Package towards Universal Health Coverage over the last two decades in Morocco. The study was conducted in Rabat the capital of Morocco where most of health policymakers and program managers of SRH are based as well as stakeholders, concerned partners, private sectors and NGOs. This study was carried out between November 2019 and May 2020. The population surveyed included policymakers and actors involved in health priority-setting process in order to identify the fundamental values related to provisions for population coverage of UHC in Morocco, especially the integration of infertility care services on the SRH benefit package (see Table ​Table2).2). The actors selected are those who were involved in the process of developing the national reproductive health strategy in Morocco, which involves the organization of workshops to debate and reach consensus on national priorities and the development and validation of the 10-year national reproductive health strategy. Interviews of key informants and where they worked National stakeholders were stratified into three groups: Regarding the participant selection, we considered that including all stakeholders was useful to draw up a global view and gain a historical perspective on the reform processes and the involvement of different actors on SRH care services within universal health coverage in Morocco, with a special interest to the infertility care services which still appears to be problematic. In fact, we included in our stratified sample, the health care providers at different levels (operational, provincial and regional), as well as the private sector; decision-makers and actors from other departments involved in the management of financial and support mechanisms for SRH programs and universal health coverage in Morocco. We also included the vulnerable groups (infertile couples) whose authorial voice added richness to the analysis. Indeed, recruitment of the infertile couples was facilitated through NGOs after their informed consent. A specific consent form was presented and explained to each participant and interviewee with the insurance that their anonymity will be preserved. We used two main methods for data collection: a desk review and key informant interviews. A data extraction sheet was used for the review of scientific articles, reports, MOH reports and national documents, related partners reports and documents, and relevant independent research report and papers. The desk review was limited to English and French documents which were published between January 2000 and December 2019, and without any methodological restrictions. Semi-structured interview guides adapted to each category of our sample, presented in Table ​Table2,2, were used to discuss the following questions: A focus group guide was elaborated based on the preliminary results of the individual interviews in order to explore in depth some issues. The interviews and focus group discussions were recorded after the informed consent of the participants. The guiding framework for our analysis was the various components of the adapted framework from Shiffman and Smith (2007). The analysis of 50 documents provided an effective and valuable tool for researchers who were undertaking comparative studies of policy implementation [18]. The sheet, used for the analysis of the selected documents, was structured and guided by the key items of the study framework. In addition, the documentary analysis provided supplementary data that we used to contextualize and clarify the second method of data collection used for this case study (interviews and group discussion). The interviews and focus groups were fully transcribed and analyzed manually, by the health sociologist, using the “content analysis” approach; the process of analysis reduced the volume of text collected, identified group categories together and sought some understanding of it [19]. In some way, we attempted to “stay true” to the text and to achieve trustworthiness [20]. The analysis included the following steps: The study was approved by the Ethics Committee of Biomedical Research of the University Mohammed V of Rabat, under reference: 17/20 on January 17th 2020; and WHO Ethics Review Committee. Individual written consent was sought from all study participants. The participants were adequately informed of the purpose of the study, their willingness to participate in the study without any coercion, the benefits and adverse effects of participating as well as the preservation of their confidentiality if they participated to the study. They were also informed that they are free to withdraw from the study at any stage. Participation in this study did not involve any risk to the participants.

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