Sweden's IVF debate raises larger questions about our health systems

Ulf Kristersson, Prime Minister of Sweden, has proposed expanding access to publicly funded IVF services for people who already have a child and want to have further children (see BioNews 1342). This immediately caught my attention, as someone who has spent several years working with patient communities, clinicians and policymakers on fertility-related issues across Europe, and particularly in Scandinavia.

What struck me, even more than the specifics of Kristersson's proposal, is how this discussion is being framed in demographic terms. Media coverage has focused on Sweden's record-low birth rates – the country's total fertility rate currently sits at around 1.42 children per woman – with an implicit assumption that fertility support should become part of the response.

Yet after years of working in this space, I cannot help but feel that the more interesting conversation lies elsewhere. Is this really just a debate about fertility treatment as a fix to sinking demographic numbers? I'm inclined to think that the core question is actually whether our health systems are evolving quickly enough to reflect how people live today.

Healthcare systems are, perhaps inevitably, built around assumptions – about healthcare needs, family structures, life stages and patient journeys. Many of these assumptions emerged during a period when life followed a slightly more predictable sequence, from completing education and starting work to forming a partnership, having children, and eventually retiring.

A wealth of literature, data and reports attest to the fact that for increasing numbers of people, this familiar sequence no longer looks so linear. People establish careers later. Housing pressures are greater. Relationships and family structures have become more diverse. Life expectancy has increased. Expectations around identity, purpose and personal fulfilment have evolved. Judging by my own circles of relatives, friends and more distant acquaintances, I suspect that all of us have experienced these developments in some measure.

None of this is inherently problematic. Societies change. An interesting question, however, is whether our institutions can change with them quickly enough.

Take fertility as an example. When birthrates decline, public discussion often moves rapidly toward demographics and economics. We start asking questions about ageing populations, workforce sustainability and future pressures on healthcare and pension systems. These are entirely legitimate concerns, but individuals rarely experience these issues in those terms.

People do not wake up thinking about dependency ratios or population curves. They think about whether they feel emotionally ready to become parents, whether they can afford a larger home, and whether their work environment makes parenthood feel feasible. They think about whether they have found the right partner, whether a health condition makes starting a family more difficult than expected, or whether parenthood is even part of the life that they envision for themselves.

Perhaps this is where healthcare policy can become slightly uncomfortable. The moment fertility and reproduction are approached and tackled in political terms – as is now happening in Sweden and elsewhere, for example in France – there is perhaps a risk of drifting from supporting individual choices towards implicitly judging them.

This raises a question. Can societies be concerned about declining birthrates without thereby becoming prescriptive about reproduction? I tend to believe that they can, provided that we make and accept a key distinction. The purpose of healthcare should not be to prescribe personal life choices, but rather to remove avoidable barriers, and to support people in achieving their own family-building goals.

Another question follows from this. What exactly are we asking fertility services to accomplish? Are we trying to influence demographic trends? Reduce involuntary childlessness? Improve equity of access? Recognise evolving family structures? Support patient choice? The answer matters because each objective leads us toward a different set of policy choices.

Many patient and advocacy organisations across Europe – including groups such as PET (the Progress Educational Trust), Fertility Europe, Väestöliitto, Red Infértiles, Association Collectif BAMP and many others – have consistently highlighted that access to fertility care is first and foremost a question of equity, inclusion and reducing avoidable barriers. Viewed through that lens, the central value of expanding access to fertility services should be about ensuring that people facing involuntary childlessness, or barriers to family-building, are not prevented from pursuing their aspirations because of geography, economics, biology or outdated assumptions.

The next question is, access for whom? Think of same-sex couples, single parents by choice, blended families, people delaying parenthood, people pursuing fertility preservation because of a medical condition, and many other specific real-life situations. Who is included when we discuss access to fertility treatment? Whose definition of family becomes the reference point? This dimension of the issue can all too easily be forgotten or neglected.

These are not purely reproductive health questions or debates about how many more live births should occur in a given country over the next few years. These are fundamentally questions about equity, and about the model of society in which we want to live.

Across Europe, from Brussels to national capitals, there is growing discussion about the societal shifts placing pressure on healthcare systems. Understandably, much of that conversation focuses on making systems more efficient, but perhaps efficiency is only one side of the equation. Perhaps we should also ask how healthcare systems can become more adaptive to how societies evolve, even down to their constitutive values.

Ultimately, the million-euro question that policymakers should be tackling may not be 'How do we encourage more births?' Instead, it might be 'How do we design systems that remain equitable, sustainable and patient-centred, as societies change?'

The role of the patient voice in healthcare system reform goes beyond understanding diseases and system gaps, and is fundamentally about understanding how people aspire to live. Healthcare systems ultimately exist not for demographic indicators, but for people.