In this study we investigated trends of allocation of ART clinics allocation over the previous twelve years in mainland China. We also evaluated the equity of distribution of ART clinics. This analysis indicates that the number and accessibility of ART clinics in mainland China increased significantly from 2006 to 2018. In 2018, the number of ART clinics in China was almost at the same level as some developed countries, for example, 502 clinics in the US [22] and 607 clinics in Japan [23]. The Gini coefficients showed that from 2006 to 2018, the equity of distribution of ART clinics improved greatly, reaching relative balance overall. The distribution of IVF clinics in eastern China and ART clinics in eastern China and central China reached absolute equality.
Since the promulgation of policies on authorization and allocation of ART clinics in 2013, the growth rate of ART clinics in China has slowed down. It is required that authorization of a new ART service must refer to the evaluation by a randomly composed national experts group, and assisted reproductive clinics must operate AI for more than one year before they can apply for IVF/ICSI technology, and operate IVF/ICSI for at least five years before they can apply for PGT[2]. As the total number of clinics gradually approached the upper levels of the plan, in the second stage (2012–2018) eastern China and central China mainly expanded IVF and derivative technologies within existing ART clinics. In three regions the number of ART clinics without IVF authorization in western China grew fastest from 2012 to 2018, illustrating that there were still more potentialities for development in western China.
Despite ART becoming a mainstream medical intervention for infertility, the accessibility of ART clinics in western China was still at a low level in 2018, which implied several factors. On the one hand, the previous analysis had indicated that ART clinics were more likely distributed in cities with large population, which is consistent with ART clinic distribution in the United State [11, 24]. Many provinces in western China have the geographical characteristics of vast territory and sparse population, and much of the territory is at high altitude. Thus access to clinics is difficult for many people. On the other hand, the stringent accreditation requirements for ART clinics in China mean that the cost is high [25]. The high investment needed for facility construction, advanced equipment, professional technology, and human resources could be intangible impediments efforts by local government to establish ART clinics. In China, infertility treatments are not yet subsidized through the national health insurance scheme. Residents' income determine whether they are willing or able to make full use of ART. A previous study in Australia showed that women in the disadvantaged social-economic class had a 6–16% reduction in access to ART treatment, and women living in regional and remote areas had a 12% reduction. When the out of pocket cost of ART treatment was increased by one third there would be a 21–25% decrease in access to treatment [26, 27]. The overall economic development of western China, lagging behind that of the eastern and central regions, has resulted in the shortage of both the supply and utilization of ART services.
In the future regional allocation, the geographical and social-economic characteristics of western China should be taken into consideration. Basic infertility diagnosis and treatment technologies, such as prevention and screening of impaired fecundity, reproductive health education, AI and other cost-effective treatments should be given priority. In addition, local monitoring and tele-medicine can be used to relieve some of the cost burden for patients in areas without advanced ART services. In the second health care system reform since 2010, the Chinese government has attempted to resolve the disparity of medical resources by grouping medical institutes of different levels into a regional medical consortium [28]. Establishing and promoting dual referral systems and appointments, data browsing between hospitals and regional information systems, and remote consultation services are part of the reform goals [29, 30]. These changes will offer opportunities and raise a promising prospect for improving the availability and accessibility of ART treatment.
Looking specifically at the provincial level, out of the 31 provinces Anhui, Gansu, Sichuan, Shaanxi, and Tibet had the least accessibility to ART clinics, while the distribution characteristics of ART clinics differed. Anhui and Sichuan are two of the provinces with large population, but the number of ART clinics is less than half of that in other provinces with the same population size. Shaanxi and Gansu province, with middle-level population size, had a relatively small number of ART clinics, and all the ART clinics were centrally located in the provincial capital. In future, government could consider increasing the number of ART institutions for the above four provinces in order to improve the accessibility of services. Moreover, attention should be paid to balancing the distribution of newly established institutions within the province.
Tibet is a special case. In Tibet, with an average altitude of more than 4000 meters, 95.5% of the population are Tibetans, and the rest are Han or other minority groups [31]. To the authors’ knowledge, merely a few studies published internationally have described the incidence rate, physiological mechanism, and therapeutic results of the infertility for the plateau inhabitants. One research paper suggested that native Tibetan males had higher incidence rates of azoospermia and severe oligozoospermia than the immigrant Han in Tibet [32]. Another study showed that the clinical manifestations of polycystic ovarian syndrome (PCOS) in Tibetan patients were significantly different from those of Han patients, and the prevalence of PCOS in Tibetan areas is slightly higher than in other regions [33]. In view of the extreme particularity of the geographical environment, demographical characters and ethnic differentials in Tibet, more target investigation should be meticulously designed and implemented, in order to better understand the needs and provide appropriate infertility treatments.
This study has certain limitations. First, it was assumed that if one or more ART clinics was located in a city, all residents in the city had access to ART services. Some factors, such as the great distance and high cost, that discourage people from utilizing fertility health care, were not taken into account. From this perspective, the estimation of 179.5 million reproductive-age population with no access to ART services may be lower than reality. On the contrary, some advanced ART clinics, located near the border of provinces, could attract patients from outside the province [24]. That might cause overestimation of people with limited accessibility. To better recognize and furthermore reduce the inequity in provision of ART services and lower the barriers utilization of those services, more endeavors in related research will be needed in future. This study has tried to offer a glimpse of the development and distribution of ART clinics in China by available empirical evidence. It is hoped that these results can serve as an impartial and objective benchmark for future policy making and assessment in China.